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REDUCING WEIGHT 
COMFORTABLY 

THE DIETETIC TREATMENT OF OBESITY 



REDUCING WEIGHT 
COMFORTABLY 

THE DIETETIC TREATMENT 
OF OBESITY 



BY 
PROF. GUSTAV GAERTNER, M.D. 

VIENNA 



AUTHORIZED TRANSLATION IN ENGLISH 




PHILADELPHIA & LONDON 
J. B. LIPPINCOTT COMPANY 



^C'^^'^ 

\-i^ 



COPYBIGHT, 19 14 
BY J. B. LIPPINCOTT COMPANT 



Elecirotyped and Printed by J. B. Lippincott Company 
The Washington Square Press, Philadelphia, U. S. A. 



SEP 26 1914 



CI.A379699 



PREFACE 

On the day on which I write these hnes 
I have commenced my two thousandth 
obesity treatment. I have satisfactorily 
completed sixteen or seventeen hundred 
such treatments, or, in other words, I have 
in each case dismissed my patient at the 
end of the treatment, having effected the 
reduction in weight which at the begin- 
ning of the treatment I pronounced 
desirable. 

Almost without exception the patients 
undergo the treatment at home. They 
pursue their usual tasks, undisturbed even 
though these are such as to make unusual 
demands upon the intellect and the 
'^nerves/' As proof of this I may cite 
the fact that many physicians have fol- 
lowed my directions for months with com- 
plete success and without any interruption 
of their difficult and trying professional 
duties. 

My results will bear comparison with 
those recorded in the literature of the sub- 



PREFACE 

ject ; in various directions will even surpass 
them. 

Let me say in advance that I am 
undertaking neither a historic presenta- 
tion of the subject nor a criticism of other 
methods of treatment. I propose to 
limit myself to a description of the 
methods by which I have succeeded in 
reducing the weight of people living 
under the most different conditions — men, 
women, and children, sick and well — by 
the amount deemed advisable: in some 
cases only two or three kilogrammes, in 
others as much as forty kilogrammes. 

The method which I now use, although 
improved in details, as the result of con- 
stantly-increasing experience, is essen- 
tially the same as that which I have em- 
ployed since 1903. 



f.%^' 



CONTENTS 



Chapter 1 9-16 

The ergostat. Graduated muscular exercise. 
Muscular exercise is not a promising and not a 
productive method of reduction of weight. Con- 
sumption of fat in walking on level ground and 
in mountain climbing. Short and intermittent 
treatments unsatisfactory. My first and second 
successful cases. 

Chapter II 17-27 

The biological significance of fat. Fattening and 
the consumption of fat. Fat as an "iron" store 
of nutriment for times of famine and sickness. 
The cushion of fat as a protection against the 
cold. An excessive fatty content should never 
be permanently retained. The "oscillating" 
body weight. The ideal condition is a constant 
weight. Gradual or rapid decrease in weight. 
Influence of pregnancy on the weight. Influence 
of marriage in the case of men. Reduction a 
physiological process like fattening. Reduction 
not dangerous for healthy men and for the 
majority of invalids. 

Chapter III 28-34 

Obesity treatments in cardiac cases. They are 
not merely permissible, but urgently indicated. 
The work accomplished by the heart depends 
among other things upon the body weight. Dys- 
pnoea of obese cardiac cases. 

Chapter IV 35-54 

The different kinds of obesity treatments and 
methods. Unfounded fear of " under-nourish- 
ment." Obesity treatment and under-nourish- 
ment almost identical conceptions. Increase of 
consumption without recording the food eaten 
generally ineffectual. Double significance of 
the word "satiation." Very many men eat too 
much. Only a part of this number is fattened, 
i.e., puts on an excess of fat. Disposition. In- 
fluence of the organs with internal secretion. 
Thyroid gland preparations as reducing agents. 
Carthartics. 



CONTENTS 

Chapter V 55-69 

Further impracticable methods of reduction. 
The sweat-bath. The sweat-bath may be com- 
bined with the dietetic treatment in oedema. 
Training of jockeys according to my method. 
Indispensability of the sweat-bath as a means 
of reducing the weight for a few hours to the at- 
tainable minimum. Massage useless as a means 
of reduction, useful in many complications. 
Attempt to reduce certain localities by massage 
during the dietetic treatment. Iodine. Faradi- 
zation of the muscles, injection of colloid metal. 

Chapter VI 70-78 

The principles of the empirical-dietetic method. 
Rate of decrease in weight. Recording the 
weight every week. 

Chapter VII 79-85 

Food-requirement, caloric value of single foods, 
and the coefficient of assimilation, are variable 
quantities. The treatment injures neither the 
bodily nor the mental efficiency. 

Chapter VIII 86-102 

The first treatments. Influence of the daily 
minimum weight by the maximum weight. The 
regimen of the analogous case. Correcting the 
first prescription on the basis of the results of 
the first and second week of treatment. The 
first week generally brings much greater results 
than the following ones. The daily maximum 
and minimum weights. The minimum trace runs 
almost parallel to the maximum trace. 

Chapter IX 103-107 

Utilizing the first experiences. Weekly instead 
of daily records of the weight. Foods with 
slighter specific weight preferred. "Ballast" 
nutriment. 

Chapter X 108-112 

The food scales. The old model and the new. 

Chapter XI 113-118 

Concerning the supply of liquids. The drinking 
of water and of mineral waters is unrestricted. 
The treatment effects a decrease of thirst. 
6 



CONTENTS 

Chapter XII 119-124 

Drinking during meals is unrestricted. Increase 
of the sensation of pleasure while eating by alter- 
nating food and drink. 

Chapter XIII 125-128 

Alcohol. 

Chapter XIV 129-137 

Concerning the eating of bread with the chief 
meals. Immoderate consumption of bread the 
most frequent cause of obesity. 

Chapter XV 138-152 

Concerning the number of meals. The chief 
meal should be eaten in the middle of the day, the 
lighter meal in the evening. 

Chapter XVI 153-164 

Concerning satiation. Complaints about the 
sensation of hunger are only recorded in the first 
two or three days of the treatment. Satiation 
by fats or by fatty dishes not the normal satia- 
tion. "Ballast" food. Potatoes. Preparation 
of vegetables. Mushrooms. Nuts. Farinaceous 
foods; light and bulky. Nutritive value and 
capacity to satiate. The feeling of hunger ap- 
pears at the hour of the accustomed meal, but 
disappears even if nothing is eaten. "Adjust- 
ment" of the stomach to quantities of food. 
Education to moderation by the treatment. The 
quantities of food which are sufficient to satiate. 
Good chewing, slow eating, promote satiation. 
Beef soup. 

Chapter XVII 165-173 

Prescribing and carrying out a diet. Everything 
which is consumed, even the "ballast" food, is 
measured out according to weight. Sugar and 
saccharin. Foods are weighed, prepared for the 
table. The body weight is recorded every week. 
Influence of the varying water content and of 
menstruation on the body weight. The "sins of 
treatment." No cure without scales. 

Chapter XVIII 174-188 

Concerning the age of the patients, who can 
undergo obesity treatments. Lower limits: in 
girls, 12 to 13 years, in boys, 15 to 16 years. 
Large breasts of young girls. An upper limit 
cannot be drawn. Treatment of an octogenarian. 
7 



CONTENTS 

Chapter XIX 189-210 

The blood-pressure in obese people and the influ- 
ence upon it of the treatment. Frequency of 
cerebral hemorrhages and sudden death from 
heart disease in obese people. Without excep- 
tion the high blood-pressure is reduced by the 
dietetic treatment. 

Chapter XX 211-231 

Migraine and dietetic treatments. The typical, 
non-menstrual migraine is generally favorably 
influenced by the dietetic treatment. 

Chapter XXI 232-240 

Influence of the dietetic treatment upon heart- 
burn and eructation. Both disturbances disap- 
pear almost without exception during the treat- 
ment. Even people who are not obese can gen- 
erally be freed from heart-burn and eructations 
by rational nutrition regulated by the food scales. 

Chapter XXII 241-242 

Influence of the dietetic treatment upon the 
climacteric flushings and sweatings. 

Chapter XXIII 243-251 

Influence of the dietetic treatment upon men- 
struation. Examples of the regulation of this 
function in the course of the treatment. 

Chapter XXIV. 252-271 

Physical exercises, baths, sleep, during the treat- 
ment. Physical exercises support the treatment. 
Swimming especially recommended. The row- 
ing-bath. Sweat-baths do not promote the treat- 
ment. A restriction of the period of sleep only 
seldom necessary during the treatment. 

Chapter XXV 272-275 

The normal diet. It is ascertained empirically. 
A small increase in weight, which should not 
be progressive, appears in the first days of the 
normal diet. Supplementary treatments. A day 
of treatment in the week in order to keep the 
weight at the same level. 

Chapter XXVI 276-291 

Height and weight of body. Table. 

Appendix 292-312 

Fattening treatments. 

Conclusion 313 



REDUCING WEIGHT 
COMFORTABLY 

THE DIETETIC TREATMENT OF OBESITY 

CHAPTER I 

The therapy of obesity has occupied 
me for a long time. As many of my 
readers may know, in 1887 I invented and 
described the ergostat, a machine which 
has served primarily to combat corpu- 
lence. My efforts met with much 
approval at that time, and the ergostat 
quickly won a wide-spread popularity. 
Much of what I then proposed is of inter- 
est even to-day, although, as will be shown 
later, the practical deductions which I 
drew from the facts differed almost com- 
pletely from those which I then accepted 
as correct. 

The ergostat was to offer city residents 
who can neither split wood nor thresh 
grain nor take mountain trips every day 
the possibility of a graduated muscular 
exercise, which would be sufficiently " con- 
centrated " and of the sort which every 
one could easily carry out. 



DIETETIC TREATMENT 

A braked- wheel is turned by means of 
a crank. The shifting of a movable 
weight regulates the difficulty of the work ; 
that is to say, it graduates the number of 
kilogrammetres (units of work) accom- 
plished at each revolution. An indicator 
registers the number of revolutions. The 
exact amount of work assigned can be 
accomplished by the ergostat. The physi- 
cian can prescribe for his patient the 
amount of work which he thinks suitable. 

The ergostat is employed in physiologi- 
cal laboratories and clinics, when it is a 
question of studying the influence of a 
certain amount of muscular work upon 
tissue change, respiration, circulation, etc. 
I know a gentleman who for over a score 
of years has turned the ergostat with 
wonderful perseverance every day on 
which he could perform no other physical 
exercise, and who attributes his good 
health and his normal figure in no small 
measure to his habit. But this man is a 
rare exception. 

Experience has taught me, and cer- 
tainly all who have been occupied with 
the subject, that the opinion expressed 
by Bunge concerning the exclusive fit- 

10 



OF OBESITY 

ness of muscular exercise for the reduc- 
tion of superfluous fat is not correct. I 
would even go so far as to express the 
opinion that among the different means 
of effecting a reduction of obesity muscu- 
lar exercise is the least promising. Not 
that there is anything hazy in the physio- 
logical principles regulating the increase 
of tissue-change by means of exercise! 
On the contrary, nothing is more certain 
than this part of the theory of tissue- 
change and of nutrition. The obstacle 
is to be found in the nature of our 
patients. 

I have often succeeded in converting 
a glutton to moderation and in weaning 
alcohol-drinkers and tobacco-smokers 
from their habits. Yet my arts of per- 
suasion have never succeeded in curing 
a lazy man of his inactivity, nor in stimu- 
lating him to take up regular physical 
exercise in any form whatever. To be 
sure, this is successful for a few weeks 
in a health resort where walks lasting 
many hours must be taken by all the 
patients, and where nothing else, or at 
least nothing more important, can be 
found to do. As soon as the invalid is 
11 



DIETETIC TREATMENT 

home again, however, he relapses into the 
old inactivity beyond recall. 

The man without experience is very apt 
to over-estimate (quantitatively) the in- 
fluence of muscular exercise upon tissue- 
change. Very frequently I hear com- 
plaints about the injustice of the fate 
which puts fat on its victim although he 
takes a daily walk or is kept much on his 
feet by his calling. 

One gramme of fat when transformed 
into work produces almost 4000 kilo- 
grammetres, and would hence be suffi- 
cent to do the work which is necessary to 
lift a man weighing 80 Kg. 50 metres 
high. Now the motor which represents 
the muscular apparatus of man works 
with a mechanical efficiency of about 30 
per cent. Therefore about three grammes 
of fat are required in the work mentioned. 
According to Rubner, a man weighing 
70 Kg. in walking one hour on level 
ground over a distance of 3500 metres, 
consumes 12.8 Gm. of fat more than when 
at rest; in climbing 150 metres (high) 
over a distance of 3500 metres, 20.2 Gm. 
of fat more. These figures plainly teach 
us that by ambulatory exercise alone eight 

12 



OF OBESITY 

hours of walking on a level or five hours 
of mountain climbing would be required 
for the removal of 100 Gm. of fat or about 
140 Gm. of fatty tissue in a day. 

There are many permissible ways of 
removing superfluous fat. None of them 
makes so great demand on the will power 
and endurance of the patient as the ones 
which require the exclusive use of in- 
creased muscular work to attain their 
end. 

This consideration caused me to try the 
other means, too. First, I did what is 
customary in such cases: I recommended 
my patients to visit a health resort or a 
sanatorium in which obesity treatments 
are given. There, if all went well, they 
lost in the course of three to five weeks, 
under the combined effect of all " methods 
of treatment," two to five kilogrammes. 
There were even some whose decrease in 
weight could only be expressed in frac- 
tions of a kilogramme, and those who 
showed no decrease at all, although they 
alleged that they had followed " every- 
thing " faithfully. Even the " success- 
ful " cases had given rise to a familiar 
and disappointing observation. Hardly 



DIETETIC TREATMENT 

had they left the Hmits of the health 
resort when the weight of the body, 
which had been forced down by depriva- 
tions and tortures, began to rise again. 
Within a few weeks the old level was 
reached. If the disposition to put on fat 
had not changed, then, very likely, the 
weight became greater than before, and 
the indication to seek the health resort 
again became more urgent with each suc- 
cessive year. Who does not know of peo- 
ple who with unrelenting determination 
have visited a health resort every year for 
decades in order to lose weight, and in 
spite of that have accumulated enormous 
burdens of fat? Some years ago I saw 
a gentleman who had already celebrated 
a jubilee of his visit and who then 
weighed 192 Kg. 

Nothing is further from my mind than 
to reproach the physicians practising in 
the health resorts or to criticize the treat- 
ments usual in the health resorts. I only 
wish to agree with those who do not con- 
sider it proper to treat a sickness of an 
obstinate nature and inclined to relapses 
by an intermittent treatment which is 
limited to a few weeks every year and 

14 



OF OBESITY 

which is even then relatively insufficient. 
For there can be no doubt that not enough 
has been done when a man weighing 50 
Kg. above the normal weight is only tem- 
porarily relieved of five or six kilo- 
grammes. 

As so often in life, a single case of 
necessity led me to give up the old model 
and to set out in new paths. 

A distinguished young actress whose 
role demanded dancing and singing, at 
times even singing while dancing, was 
afflicted with the unhappy disposition to 
obesity. 

One day — it was in 1902 — she implored 
my aid. She said that she was no longer 
able to practise her calling, and had al- 
ready tried every means of becoming 
lighter and more active. Without suc- 
cess ! An interruption of her professional 
duties was impossible for reasons not nec- 
essary to mention. Hie Rhodus, hie salta! 

I myself was at that time a suitable 
subject for an obesity treatment. There- 
fore I experimented for some weeks on 
myself and found that my expectations 
proved right : that the treatment advanced 
while I perceived no deprivations and 

15 



DIETETIC TREATMENT OF OBESITY 

remained in excellent health. Then 
I plucked up courage to call upon the 
artist to become No. 2 of my experimental 
subjects. With characteristic enthusiasm 
she agreed, and stood it bravely for weeks 
and months. Then we were delighted to 
see how kilogramme after kilogramme 
vanished and how the earlier activity re- 
turned again. This established for me 
the possibility of conducting a treatment 
of obesity up to the desired result without 
disturbing the patient even for a single 
day in an occupation taxing alike physical 
and mental powers. 



16 



CHAPTER II 

In the organic world we find wide- 
spread a wonderful arrangement. In 
times of surplus nutrition stations are 
created which help out in times of need. 
In the plant kingdom these stores con- 
sist chiefly of carbohydrates (starch and 
sugar) and of fat; in the animal king- 
dom, almost exclusively of fat. 

Like many of our domestic animals, 
man is also easily fattened; that is, a sur- 
plus of nutriment which has been con- 
sumed is accumulated in the form of drops 
of fat in a tissue of its own — the fatty 
tissue under the skin — but also in other 
places, as in the diaphragm, the peri- 
cardium, and the liver. 

It is no longer doubted that the three 
chief groups which compose our nutri- 
ment — carbohydrates, fats, and albumin- 
ous bodies — are able to bring about the 
formation of fat. The experience of those 
who fatten animals teaches this just as 
convincingly as do numerous tissue-change 
experiments in the case of men and 
animals. 

2 17 



DIETETIC TREATMENT 

But the physiological significance of the 
fat deposited in the fatty tissue we learn 
from wild animals. They put on fat in 
summer and consume their fat in winter. 
Many hibernating species who go for 
months without nourishment can provide 
meanwhile by the oxidation of their fat 
for the necessities of tissue-change, which, 
it is true, are somewhat reduced. We 
fatten our domestic animals — swine and 
geese in order to gain for ourselves valua- 
ble fat, or (beef, sheep, chicken) in order 
to make their muscles, w^hich are in- 
filtrated with fat, more palatable and of 
greater volume. 

A certain degree of fatty element is 
very advantageous for man himself. A 
man extremely deficient in fat can not be 
considered altogether normal. The ex- 
ternal appearance is unfavorably in- 
fluenced by a too small degree of fat, 
especially in women and children. The 
skin, particularly that of the face, allows 
the bones and muscles lying beneath to 
protrude too much, and is lacking in 
lustre and elasticity. This is much less to 
be feared in men. So long as the muscu- 

18 



OF OBESITY 

lar system is well developed the fat may 
be reduced to a small quantity. 

Beauty of face does not suffer thereby, 
still less that of body and limbs. A man's 
countenance should show well-defined 
lines which are not rounded off and ob- 
literated, and the contour of every muscle, 
of every bony prominence, and of many 
sinews should be plainly visible under a 
thin skin on the body and at the extremities. 
Excessive poverty in fat itself, however, 
distorts the face of an otherwise healthy 
man to that of an old man. We see this in 
jockeys, who, because of their occupation, 
must sacrifice the last pound of their fat 
in training. But a disfiguring influence 
of reduction is only to he feared when the 
fatty content of the body sinks below the 
normal, not, however, in a treatment which 
is kept within reasonable bounds. 

However, the most important function 
of fat is this: it is an iron store of nutri- 
ment, which is consLmied in time of want 
and which suffices, as we learn from many 
chance observations and experiments 
carried out by " hunger artists," to sus- 
tain in action all the vital functions and 

19 



DIETETIC TREATMENT 

thereby life itself for several weeks. ( The 
organism can dispense with water only 
for a few days without collapsing.) 

Since the time of railroads and the de- 
velopment of a marine commerce, Eu- 
rope, as well as all other human settle- 
ments which are involved in the dense 
world trade, has been spared actual 
famine. Yet in India and China millions 
of men die of hunger when the crops fail. 
There is no doubt that fat men survive 
a famine better than lean ones. As has 
been mentioned, at least at present there 
is no question of a famine for us, although 
even in this country single individuals die 
of hunger. 

However, it occurs altogether too fre- 
quently that sickness hinders an individual 
in taking or assimilating food, entirely or 
in part. Then circumstances develop 
which correspond to the real hunger con- 
dition. If the illness is accompanied by 
fever, we are confronted by the fatal com- 
bination of an increased demand and a 
decreased or almost entirely arrested sup- 
ply of nutriment and fuel. A hungry 
man who is at the same time in a fever 

20 



OF OBESITY 

consumes his fat faster than a healthy- 
hunger artist. 

Now, each one of us is exposed to this 
*' hunger danger," and it is just as clear 
theoretically, as it has been shown through 
observation, that a man equipped with a 
normal cushion of fat can survive such 
" consuming " diseases more easily than 
an excessively lean one. 

Still another function is to be attributed 
to the cushion of fat. As a poor conduc- 
tor of heat it protects the body like the 
clothing in times of cold, and under these 
circumstances facilitates the regulation of 
heat and the maintenance of a constant 
body temperature. The huge layers of 
fat of the mammals and birds living in the 
waters of the polar regions have this task 
to fulfil. Since the water in which these 
animals live draws much more heat from 
the body than the air does, and since, 
moreover, the temperature of this water 
often reaches down close to the freezing 
point, a truly enormous demand for nutri- 
ment and fuel would be imperative to 
keep these organisms continually at a 
temperature which is so very different 

21 



DIETETIC TREATMENT 

from that of the surrounding medium/ 
An example of the loss of this function 
is to be found at times in cases of radical 
obesity treatments in winter. If there is 
a decrease of five or more centimetres in 
the fatty layer of the body and also a 
considerable decrease at the extremities, 
then certain invalids are wont to complain 
about feeling the cold when the tempera- 
ture is lov/. It is almost the same condi- 
tion which occurs when their clothing, or 
at least a layer of their covering, is 
removed. 

Since man, fortunately, does not live 
in the waters of the polar sea, and, more- 
over, since he can protect himself from 
excessive losses of heat by suitably- 
chosen clothing and by the heating of his 
dwelling rooms, the presence of a thick 
layer of fat is of no use to him as a heat 
insulator. The advantage which it would 
give in winter would be outweighed by the 

^The food requirement of mammals living in cold 
water is always enormous, in spite of the heat-insulating 
layers of fat. The walrus, whose weight is about equal 
to that of the ox, consumes in 24 hours no less than 50 
Kg. of fish. I take this statement from C. Hagenbeck's 
" Guide through Stellingen." The stimulating effect of 
the cold bath on tissue-change, of which more explicit 
mention will be made in a later chapter, is in this way 
most excellently illustrated. 

22 



OF OBESITY 

disadvantage which it would cause its 
wearer here in summer and in hot chmates 
at all seasons. Rubner has pointed out 
that heat regulation is rendered much 
more difficult for obese people in warm, 
damp air, from which they receive mani- 
fold disagreeable consequences. 

In organisms which periodically take on 
fat in time of excess nutriment, the oxida- 
tion of this store in time of want of nutri- 
ment is a normal, physiological process. 
We would doubtless disturb the health of 
these animals were we to keep them per- 
manently fat by removing the lack of food 
in winter. 

It is a well-known fact that domestic 
animals which are hard to fatten (swine, 
geese) have, while being fattened, much 
more delicate health — indeed, must be 
considered positively sick. We do not try 
to fatten these and other animals for the 
purpose of prolonging their life. 

As has already been said, man belongs 
to the organisms who can take on fat with 
abundant nutriment. Aside from the 
" iron store " which is to be kept per- 
manently and which we should attempt 
to restore by a fattening treatment when 
it fails, a supply of fat beyond this 

23 



DIETETIC TREATMENT 

measure should he at most merely tem- 
porary, hut never permanent. 

It is observed that season workers put 
on fat and increase in weight at the time 
of their occupation, and become lean when 
their work is scarce, chiefly in winter. On 
the other hand, we see members of those 
classes of society who eat their fill at every 
season become fatter in winter at the time 
of the flood of our social aff*airs, the chief 
object of which seems to be either to 
fatten the guests by delicately com- 
pounded meals or to destroy their stom- 
achs and sleep. If these men, as often 
occurs, eat and drink less abundantly and 
take more exercise (or at least go walk- 
ing) in simmier, then they can consume 
their winter fat again. Their weight 
sinks back to the old measure. This state, 
the oscillating weight, can be considered 
permissible so long as it is kept within 
definite, narrow bounds. However, the 
ideal condition of a man who does not 
have to fear famine is the constant 
weight. It happens far too easily that 
once or several times the compensating 
decrease does not occur, and then the 
effects of the fattening periods total up to 

24 



OF OBESITY 

threatening values. Much worse are 
those who fatten themselves without any 
interruption or alternation 365 days in 
the common and 366 days in leap year. 

To take on 10 Gm. in weight in a day 
does not matter much. In a year, how- 
ever, this has become 3.65 Kg., and in 10 
years 36.5 Kg. Each one of us know men 
who have stored up by such consistent 
economy 70 and more kilogrammes over 
the permitted measure. 

In other cases the patients report to us 
that the tendency to take on fat has been 
present for a long time ; that their weight 
has grown steadily but slowly; then, how- 
ever, beginning at a certain time, the rate 
of increase has hastened rapidly. Cases 
in which the patient gains 20 Kg. and 
more in a year are not uncommon. In 
women what brings about the rapid in- 
crease is generally pregnancy — this it- 
self or the following lactation; but, to go 
deeper, the unreasonable method of diet 
(beer in immense quantities as a drink!) 
which is demanded at this time by almost 
ineradicable prejudices. The appearance 
of the climacteric, as we shall see later, is 
likewise not seldom accompanied by rapid 

25 



DIETETIC TREATMENT 

rise in weight. In men the rapid addition 
of fat can often be dated from their mar- 
riage. A quieter and evener Hf e and more 
abmidant nutriment with " favorite 
dishes " are the probable causes of this 
frequent phenomenon. 

Every addition of fat which exceeds the 
iron store ought to be temporary. Its 
continuous existence is the cause of dis- 
advantages and even dangers. Ohese peo- 
ple should know and always keep before 
their eyes the fact that the removal of fat 
is a normal, physiological process^, the 
integrant second half of the accumulation 
of energy, which has been arranged so 
suitably by Nature. The stored-up, super- 
fluous fat must be consumed again, and 
not always increased, if the organism is 
not to collapse and choke under the burden 
(taken also in the literal sense). 

When the lean times, for which the fat 
is designed, do not come of themselves, 
they must be artificially produced. When, 
however, the fat is once removed, we 
should aim to keep the body weight con- 
tinually at the same height. Neither the 
climate nor the other conditions of life 
under which by far the greater part of 

26 



OF OBESITY 

civilized mankind lives makes it desirable, 
or even permissible, that we put on and 
take off fat alternatelj^ However, if we 
have put on fat, we must take into the 
bargain the removal of fat. 

Like all other physiological processes, 
the oxidation of superfluous fat is con- 
nected neither with dangers nor disadvan- 
tages to the organism. Assertions and 
apprehensions to the contrary are without 
foundation. This holds not only for the 
man whom we characterize as healthy, — 
that is, one who exhibits no disturbances 
of the important functions recognized by 
himself or the physician; this holds also, 
with few exceptions, for the invalid ; above 
all, for the cardiac case. 



27 



CHAPTER III 

In this, as in many other points, my 
experience coincides with that of Von 
Noorden, who not merely declares it per- 
missible to reduce the flesh of cardiac 
cases, but who has found, on the contrary, 
that no greater and more important ser- 
vice can be shown to an obese sufferer 
from heart-disease than to relieve him of 
his burden of fat. The stout cardiac case 
suffers much more from his great weight 
than does the healthy man. 

The work to be accomplished by the 
heart is determined by many factors. One 
of the most important of these is provid- 
ing the muscular system with blood. The 
blood requirement is entirely different, 
according as the muscular system rests, 
so far as this is possible (the respiratory 
muscles and the cardiac muscle never 
rest), or as it accomplishes work. In the 
latter case the demand is considerably 
greater, and, what is more, grows with the 
amount of work which the muscles per- 
form. We often see cardiac cases who 
feel tolerably well so long as they are 



DIETETIC TREATMENT OF OBESITY 

lying in bed or sitting quietly; that is, so 
long as the muscular system of their bodies 
continues in almost complete inactivity. 
As soon as they attempt to make the 
movements necessary in walking, phe- 
nomena of cardiac insufficiency appear, 
phenomena which indicate that the heart 
is no longer equal to its task. Walking 
has increased the demands on the heart. 
In other and, fortunately, more frequent 
cases these patients can even cover long 
level stretches without being conscious of 
their ailment. Cardiac insufficiency, how- 
ever, appears when they begin to mount 
stairs or elevations. In doing this, be- 
sides accomplishing the work which the 
horizontal forward movement necessitates, 
they must also raise the weight of their 
bodies. The heart is no longer equal to 
this greater task. 

Moreover, the working capacity of the 
healthy heart may not be exceeded with 
impunity. A very considerable part of 
the professional athletes finally become 
victims of cardiac diseases. 

The amount of work which the heart 
does stands in direct relation to the body 
weight. The greater the body weight, 

29 



DIETETIC TREATMENT 

the greater the burden which the body 
muscles are obhged to hft and to move. 
The more the muscles are taxed, the more 
work the heart has to do in order to keep 
pace with the great demands of the in- 
creased blood supply. Relatively a much 
greater amount of blood flows through 
the working muscle than through the 
muscle at rest. When many and large 
muscles are brought into action, the path 
of the blood is enormously extended, and 
the heart must set in motion a much 
greater quantity of blood in the unit of 
time than when the muscular system is at 
rest. 

If labor is not excessive, and for those 
who have been trained for the particular 
kind of work, the blood-pressure, as my 
own observations have taught me, re- 
mains unchanged. The amount of work 
done b}^ the heart must accordingly in- 
crease in proportion to the rise of circula- 
tor}^ activity. Every additional kilo- 
gramme which is loaded upon the muscu- 
lar system is felt by the heart. Regard 
for the heart determines the load which 
the soldier bears. He is made to carry 
as great a burden of weapons, ammuni- 
tion, etc., as his heart (i.e., the average 



OF OBESITY 

heart of a young man) can stand without 
danger. However, when he is about to 
be called upon to endure long marches 
or other unusual exertions, he is made to 
lay aside everything in his equipment 
which is not absolutely indispensable. 

The obese man is in the position of a 
soldier who is unreasonably burdened. In 
general it is of no consequence for the 
muscles of the legs and the body and like- 
wise the heart whether the burden is situ- 
ated under the skin or outside of the skin. 
As a matter of f acif, however, the burden 
bearer or the soldier with his load is better 
off than the obese man. 

It has been ascertained by much con- 
sideration and testing how and where the 
burden disturbs least. In this way it has 
been found that free respiration is to be 
sought above all. The respiratory move- 
ments must not be hindered. Now, fat 
has the tendency to collect in especially 
large quantities in the abdominal walls 
and in the abdominal cavity (mesentery) . 
But there it hinders respiration by offer- 
ing the resistance of the abdominal protru- 
sion of the stomach to the descent of the 
diaphragm. Certainly none will ever 

31 



DIETETIC TREATMENT 

think of fastening a load to be borne 
where fat usually accumulates first and in 
especially large amount. Shortness of 
breath is one of the most tormenting 
symptoms of obesity. At first it is only 
noticed during straining exertions, later 
during every movement, and, finally, 
when the body is at rest. 

Especially tormenting is dyspnoea, 
which appears in many of our patients as 
soon as they attempt to lie down, and 
which forces them to pass their nights in 
a sitting or half-reclining position. 

Cardiac cases are often obliged to con- 
tend with dyspnoea because of their main 
complaint. Likewise obesity produces 
dyspnoea. The two influences total up in 
the stout cardiac case, and the air-hunger 
can reach an unendurable degree. Finally, 
only when absolutely quiet and in a sitting- 
position do the poor victims find air 
sufficient to maintain their lives, which 
are indeed not worth living. 

One of the two intercurrent diseases is 
generally incurable. To be sure, we can 
improve the condition of a cardiac patient 
materially by regimen and medication; 
we can impede, or for a time completely 

32 



OF OBESITY 

prevent, the functional disturbances by 
furthering compensation; but we are not 
in a position to repair a valve which does 
not close nor to widen a narrowed orifice 
in the heart. 

However, the other one of the two dis- 
eases is curable, and it is one of the most 
grateful tasks of the physician to heal, 
or at least to alleviate, it. Every kilo- 
gramme of fat removed signifies an un- 
loading of the distressed heart, a relief 
to breathing, an increase of the possi- 
bility of. motion, a prolongation of life. 

The opinion is wide-spread in medical 
and lay circles that men afflicted with 
organic heart ailments ought not to be 
subjected to treatment for obesity. My 
experience, and, as already mentioned, 
also that of Von Noorden, goes to show 
that in this particular case the treatment 
is urgently needed. The diagnosis of a 
heart lesion causes me then to recommend 
the treatment urgently to the sufferer. 

Let it be confessed, however, that in 
diseases of the myocardiuGoi, and espe- 
cially in disturbances of innervation, spe- 
cial caution should be exercised; the more 
so in order that relapses or unfavorable 
conditions, which in such cases easily 

3 33 



DIETETIC TREATMENT OF OBESITY 

occur even without ascertainable cause, 
may not be charged to the treatment. The 
inchnation to construe such " causal " 
connections — to make a propter hoc out 
of a post hoc — exists in many men. I 
myself could report " accidents the result 
of obesity treatments " which have very 
great similarity with the case of a death 
following salvarsan, which, according to 
newspaper accounts, occurred recently in 
Russia. It was revealed, upon closer 
examination of the case, that the man re- 
ceived an injection of quicksilver, not 
salvarsan, and that he did not die from 
that, but was strangled by the hand of a 
murderer. 

It was a pardonable artifice of our 
physician ancestors to assert that it is 
dangerous to life to heal this and that dis- 
ease, which, as a matter of fact, they did 
not understand how to heal. With the 
advances of therapy the number of noli 
me tangere diseases, to which belonged 
not long ago, among others, fistula of the 
rectum, chronic eczema, and plica polo- 
nica, is decreasing steadily. Even obesity 
will be stricken from this list when physi- 
cians and laity are conversant with its 
curability. 

34 



CHAPTER IV 

It happens by no means seldom that 
my patients for some reason consult a 
second physician during the treatment, 
and that they then come again and tell me 
in a reproachful tone that my colleague 
has found that they are " under- 
nourished." They, and supposedly, also, 
many physicians, connect this word with 
the conception of a very critical condition, 
which requires at least immediate inter- 
ruption of the treatment, if possible even 
the introduction of a fattening treatment. 
The establishment of a diagnosis of under- 
nourishment was made in many cases, not 
by complicated examinations of tissue- 
change, etc., but by simple medical ex- 
amination — inspection, auscultation, and 
percussion. In the great majority of 
cases a moderate pallor ^ was the only 
symptom that could have warranted the 
diagnosis of " undernourishment/' 

^ Pallor is actually observed in obesity treatments in 
about one-quarter of all cases. It disappears on the day 
on which the patients complete the treatment and re- 
sume the normal diet^ According to my experience, no 
significance is to be attached to this. 
35 



DIETETIC TREATMENT 

Now, it is absolutely necessary for every 
man who submits to an obesity treatment, 
and for every physician who carries it out, 
to know that undernourishment and 
obesity treatment are ahnost identical 
conceptions, two expressions which mean 
almost the same thing. 

As we will see directly, there are differ- 
ent ways which lead to reduction of 
weight, but without undernourishment it 
will never be accomplished. An obesity 
cure depends without exception upon less 
nourishment being given a man for a time 
than he requires for conversion into 
energy. In this way the organism is 
compelled to make up what is lacking 
from the fat which is stored up. The 
completion, however, must be at the ex- 
pense of the fat only, not of the albumin- 
ous content, and of the muscular system. 
We will return to this point later. 

Theoretically considered, there are two 
means of creating a negative balance of 
tissue-change : 

(1) Increase of output. 

(2) Decrease of income. 

In practice, however, it is often difficult 
to determine how to combine the two. 



OF OBESITY 

In the" first chapter I admitted that I 
had given up the exclusive use of muscu- 
lar exercise with its accompanying in- 
crease of tissue-change. If the amount of 
nourishment is left to the discretion of the 
invalid, one is disappointed with the 
results. As is well known, all muscular 
exertion increases the feeling of hunger. 
The invalid increases the amount of his 
nutriment with astonishing certainty at 
least up to the point necessary for the 
maintenance of his status. Every physi- 
cian with some experience has heard the 
complaints of patients who quarrel with 
their fate: "I take gymnastic exercise 
daily, play tennis, go walking or riding, 
even have myself massaged, and in spite 
of that I do not succeed in removing even 
a kilogramme of my fat." 

The increased feeling of hunger causes 
men, without suspecting it, to augment 
the quantity of their nutriment (espe^ 
cially in the form of some additional 
bread). By that, however, the effect of 
the muscular work is evened up ; all their 
trouble was in vain. It is clear what must 
happen: the quantity of nutriment must 
not be increased; the man who exercises 

37 



DIETETIC TREATMENT 

must receive no more nutriment than he 
did when he was resting. Yet a disap- 
pointment can be encountered in carrying 
out this apparently infalhble principle. 
That is to say, if the patient, before he 
increases Jiis metabolic processes by 
muscular work, has taken more nutriment 
than was necessary to combat his tissue- 
change, this quantity can still suffice to 
maintain the equilibrium if the need has 
been increased by muscular work. 

The mode of nutrition just mentioned, 
the excess diet, is, according to my con- 
victions (with reference to this there are 
other views), the rule in those classes of 
society from which the material for obesity 
treatments is drawn. Therefore, efforts 
to secure a reduction in weight by the 
increase of muscular work and the same 
amount of nutriment are without avail. 
Rare exceptions may be disregarded. 
Exhausting, repeated mountain rambles 
or daily, regular, heavy muscular exer- 
cise lasting many hours increase the tissue- 
change so powerfully that even the sur- 
plus diet during rest cannot cover the need. 
As has already been mentioned, we see 
also how energetic men can consume their 

38 



OF OBESITY 

winter fat in a few summer weeks. The 
assumption is that they must not be mis- 
led into appeasing the increased feeling 
of hunger by an abundant diet. They 
must endure a certain amount of hunger, 
if they wish to consume fat; they must 
become " undernourished." 

I have found that even exhausting and 
repeated mountain trips undertaken from 
a good hotel as headquarters seldom effect 
a substantial decrease in weight, while the 
ones which are provided with a quanti- 
tatively and qualitatively insufficient 
store of provisions frequently bring about 
this result. 

One thing we should always keep be- 
fore our eyes : even the maximum amount 
of work which men are able to accomplish 
can easily be compensated for by nutri- 
ment. Blacksmiths, ship-loaders, and the 
'riksha boys of East Asia — the latter are 
obhged to trot along for hours carrying 
a cart with a man sitting in it — do not 
consume their own tissues. When they 
find sufficient nourishment, they retain an 
even weight and good health. 

Therefore, a fat man can never be made 
slender by force of work alone. Besides 

39 



DIETETIC TREATMENT 

that, care must be taken that his diet is 
made insufficient, that the increased appe- 
tite, which the work causes, is not quite 
appeased. 

The division of obesity treatments, pro- 
posed by Bunge and widely accepted, into 
" permissible, natural ones," which con- 
sist in giving the patient work to accom- 
plish without his going hungry, and into 
" senseless hunger treatments " in which 
only his nutriment is diminished, is false. 

Even in the natural obesity treatments 
we cannot get along without reducing the 
diet, hence without hunger. In this con- 
nection it makes no material difference 
whether tissue-change is diminished or in- 
creased. The patient must not eat his fill: 
his fill in the sense that the oxidative value 
of the nutriment must not be entirely 
sufficient for the conversion into energy. 
However, this theoretical conception of 
satiation fortunately does not coincide 
with that which men perceive as satiation. 
Let it he remarked here that my patients, 
and certainly also those of other physi- 
cians of experience, suffer no hunger dur- 
ing the treatment. 

The physician who would carry out suc- 

40 



OF OBESITY 



cessf ul obesity treatments must know how 
to protect his patients from the feehng 
of hunger. By that I mean hunger after 
meals — the feehng that he has not had 
enough. Before meals every healthy man 
ought to feel hungry, and many have their 
physician to thank for acquainting them 
with this hitherto unknown sensation. 

To be sure, most obese subjects enjoy 
by nature a blessed appetite. Yet we also 
meet some who have never allowed a feel- 
ing of real hunger to develop, but imme- 
diately answer the slightest warning of 
this sort by an extra meal. 

But in the case of obese drinkers lack 
of appetite is of very frequent occurrence. 
Chronic gastric catarrh and gastric dilata- 
tions, both conditions which disturb the 
appetite, are, as is well known, frequently 
results of the immoderate use of alcohol. 

Explicit mention will be made later of 
the second kind of obesity treatment. But 
before that the pathological cases and 
their treatment must be illustrated. 

It is a phenomenon familiar even to the 
laity that of several men of approximately 
the same age, the same mode of life, 
stature, etc., who eat the same fare, some 

41 



DIETETIC TREATMENT 

put on fat while others remain lean. The 
same observation is made in the case of 
animals — at least in the direction that the 
effect of fattening turns out differently 
with the same fodder. The capacity for 
fattening which some species of animals 
have has been systematically increased by 
century-long continued breeding, and as 
a result is much more wide- spread than in 
men. It seems, however, that similar in- 
fluences depending on artificial selection 
have prevailed in the case of the female 
sex of some Oriental races, among 
whom only a stout woman is considered 
beautiful. 

Now, one might suppose that fat people 
consume more, quantitatively, than thin 
ones. This is often true; but in other 
cases parents who are intelligent and good 
observers assert that the stout child eats 
no more, perhaps even less, than its normal 
brothers or sisters. 

There is no doubt that the same nutri- 
ment is differently assimilated by differ- 
ent individuals. Not what men swallow, 
but only what they digest and assimilate, 
can be considered nutriment in the sense 
of tissue-change. These functions are 

42 



OF OBESITY 

carried on differently in different men, 
and even in the same men they can vary 
from day to day under the influence of 
external conditions. When the nutriment 
is reduced under the degree necessary to 
maintain his equilibrium it is better as- 
similated than when an excess diet is the 
rule. Magnus Lowy found that even in 
constipation all materials, cellulose in- 
cluded, are better assimilated, and that 
loss through the feces sinks from 75 to 50 
per cent. 

The same observation can be made in 
every obesity treatment. The amount of 
the stool sinks to a fraction of the former 
value and more than in proportion to the 
reduction of the amount of the diet. 

If all the nutriment exceeding the 
measure necessary to the maintenance of 
the organism in the same status were to 
be applied to putting on fat, then there 
would be many more fattened men than 
actually exist among healthy individuals, 
who are in the position freely to choose 
their food quantitatively and qualitatively. 
And if the ability to take on fat through 
the food did not cease at a certain weight 
which varies from case to case, obesity 

43 



DIETETIC TREATMENT 

would be one of the most frequent causes 
of death in this class of society. Accord- 
ing to my conviction (which is not gener- 
ally shared), most men eat too much. I 
have been able to effect a substantial re- 
duction in the diet not merely of obese 
men, but also of those with a normal 
nutritive condition, without reducing their 
weight. And the normal amount which I 
could discover experimentally for over a 
thousand men was evidently less than the 
diet which these and other men volun- 
tarily chose. 

Overeating begins even at the tenderest 
age. Infants easily overload their stom- 
achs. The reduction of the amomit of 
nutriment to the correct degree is an im- 
portant task in the hygiene of this age of 
life. But children and adults eat as much 
as they can '' get down " of agreeable 
food when it is offered in unlimited 
quantity. 

The taking of food which serves the 
maintenance of the individual is accom- 
panied in all organisms equipped with per- 
ception by pleasurable sensations. In the 
ages in which the second mighty impulse 
which brings about the preservation of the 

44 



OF OBESITY 

race was not yet developed or was already 
extinguished, these pleasurable sensations, 
the converse value of which is hunger, 
formed the most important arrangement 
in all life; but in all life one of the two 
most important biological arrangements 
whose cessation would result in the rapid 
extinction of the race. 

The endeavor to procure the pleasur- 
able sensations connected with the taking 
of food is entirely normal, physiological, 
and ought not to be suppressed but only 
directed into the right paths when it has 
degenerated. 

These pleasurable sensations must also 
be reckoned with when an obesity treat- 
ment is to be carried out. Other condi- 
tions being equal, that physician who pro- 
cures for his patients the greatest amount 
of epicurean pleasures, who imposes upon 
them the fewest restrictions, will secure 
the greatest success. His prescriptions 
will also be borne longer than those which 
demand an extensive asceticism. 

In the endeavor to obtain as much as 
possible of the pleasurable sensations 
mentioned, men — we can probably say 
most men — eat more of an agreeable dish, 

45 



DIETETIC TREATMENT 

and especially of a meal composed of a 
series of dishes calculated to tickle the 
palate, than is necessary to maintain their 
miiform weight. The first condition for 
putting on fat has been given. The sec- 
ond, the disposition, must yet be added in 
order that the patient may really be 
fattened. This disposition is present in 
many cases without our being able to 
connect it with any anatomical or func- 
tional deviation from the norm of special 
organs or system of organs. JMen are at 
first merely obese, but otherwise healthy. 
However, with time disturbances de- 
velop, which, however, are the result, not 
the cause, of obesity. 

However, in an extremely small frac- 
tion of those predisposed well-defined 
changes in the organs are found which in- 
fluence tissue-change and other vital pro- 
cesses by internal secretion. Alfred Froh- 
lich has pointed out that diseases of the 
hypophysis can bring about extreme 
obesity together with deficient develop- 
ment of the genital system. The relations 
of the thyroid gland to the accumulation 
of fat are best known. Insufficient func- 
tioning of the thyroid gland creates a 

46 



OF OBESITY 

syndrome (clinical picture) which is 
known as myxoedema. An integral con- 
stituent of myxoedema is obesity. In con- 
trast to this, in Basedow's disease, an 
affection referred by many authors to 
overfunctioning of the thyroid, we find, 
among other things, emaciation. These 
experiences and observations have prob- 
ably led to the trial of thyroid prepara- 
tions as a remedy for obesity. The count- 
less anti-fat pills and tablets manu- 
factured, especially in France, and often 
highly puffed up, contain thyroid prep- 
arations. But not always: there are also 
quite harmless cathartic pills and teas to 
which the inventors or publishers, without 
grounds, ascribe the power of effecting a 
reduction in weight. The manufacturers 
of remedies to be used externally, salves, 
soaps, etc., make still greater demands 
upon the gullibility of the purchasers. 

There is no doubt that a reduction in 
weight can be gained by thyroid extracts. 
They are employed and recommended by 
many experienced physicians, especially 
for cases which do not yield to dietetic 
treatment. 

I have not met such cases, I have been 

47 



DIETETIC TREATMENT 

able to reduce my patients, mthout ex- 
ception, hy diet and other regimen alone. 
Thus I escaped the necessity of prescrib- 
ing thyroid extracts. 

But I have also learned and seen much 
which forces me to oppose these prepara- 
tions actively. Very many of my patients, 
before they sought me, had tried, besides 
other remedies and methods, also thyroid 
extracts. The verdict which the most in- 
telligent, including even phj^sicians, 
formed about these was decidedly against 
them. 

And still a second circumstance makes 
me cautious. I saw acceleration of the 
pulse-beat appear as the only undesired 
consequence of very radical obesity treat- 
ments. I have recorded tachycardia about 
fifteen times: therefore an infinitesimally 
small percentage. In individual cases, 
moreover, there were other forces present 
besides the treatment which could be 
brought into causal connection with the 
appearance of tachycardia. Thus the 
accelerated pulse appeared once as the 
immediate result of a great overexertion. 
The young lady in question pursued a 
fleeing dog for hours up hill and down 

48 



OF OBESITY 

dale, and this resulted in a condition of 
great nervous excitement. In another 
case several weeks after, palpitation and 
acceleration of the pulse appeared during 
an exhausting mountain trip. On account 
of the time which had elapsed in this case 
the connection with the treatment was 
very questionable ; and still more improb- 
able, since the lady in question had a few 
years before gone through a very similar 
attack as the result of a touring achieve- 
ment which overtaxed her powers. In a 
third case there were present besides the 
acceleration of the pulse: slight exoph- 
thalmus, slight swelling of the thyroid 
gland, diarrhoea, therefore Basedow's dis- 
ease — to be sure, in such a light degree 
that the diagnosis was doubtful at first. 
It concerned a lady forty years old who 
had undergone a treatment with me 
four years before and had lost 14 Kg., 
while remaining in perfect health. For 
two years she kept the same weight. Then 
she became careless and took on 11 Kg. 
A year ago she came again. A new treat- 
ment brilliantly successful. Decrease in 
weight of 10 Kg. Diarrhoea and tachy- 
cardia appeared after great annoyance 

4 49 



DIETETIC TREATMENT 

and vexation. The treatment is at once 
discontinued. In spite of unrestricted 
diet, the weight sinks 4 Kg. The phe- 
nomena have since then greatly improved 
— in the meantime six months have passed 
— so that complete recovery is soon to be 
confidently expected. 

It is well known that vexation and simi- 
lar psychical traumata belong to the fre- 
quent causes, or at least the exciting occa- 
sions, of Basedow's disease. Therefore 
the case really proves nothing, except that 
an obesity treatment does not prevent dis- 
ease from breaking out. 

At any rate, it seems to me conceivable 
that there exists a connection between re- 
duction of weight and hyperthyroidism. 
The' thyroid gland and the fatty tissue cer- 
tainly stand in some kind of functional 
relation. One might imagine, for exam- 
ple, that after the disappearance of 20 or 
30 Kg. of fat the unchanged remainder 
of the thyroid gland becomes relatively 
too great. One might also suspect that 
the disappearance of fat excites a hyper- 
secretion of the thyroid gland, and might 
propose still other hypotheses which seek 
to explain the phenomenon. 

50 



OF OBESITY 

The observation of these cases was a 
warning for me to omit all medication 
whose effect tended in this direction. 
Tachycardia and palpitation are not rare 
resultant phenomena of thyroid feedings. 

Fear of harming my patients has kept 
me, therefore, from using thyroid pre- 
parations as reducing remedies, the more 
so since I always succeeded without this 
preparation. For me there is only one 
exception to the rule.^ 

When the patient shows, besides his 
obesity, still other symptoms of an insuffi- 
cient functioning of the thyroid gland 
(myxoedema), then I seize upon this 
therapy with the greatest enthusiasm, the 
discovery and development of which be- 
longs to the great advances of present-day 
medicine. Warning against the use of 
thyroid preparations without the super- 
vision of a physician can not be made 
urgent enough. In spite of the official 
prohibition, which ought to prevent the 
sale of thyroid preparations, these are 
brought to us from France under the most 
diverse designations. They have already 

^ I find myself in this respect in complete agreement 
with Umber. 

51 



DIETETIC TREATMENT 

caused many severe disturbances of the 
health. 

Other substances also, by no means im- 
material to the health, have been recom- 
mended as reducing remedies. Chronic 
cases of poisoning with arsenic and quick- 
silver are accompanied by reduction in 
weight. Surely it would be a case of 
Beelzebub driving out the devil if obesity 
were to be replaced by a chronic poisoning 
from these remedies. This consideration 
also leads me to reject the use of boric acid 
and borax, which are recommended as re- 
ducing agents. 

The purgatives deserve a place of their 
own in this discussion. For the lay com- 
prehension there is nothing simpler than 
to bring about a reduction with purga- 
tives. Fattening arises from too much 
material being introduced into the receiv- 
ing opening of the digestive apparatus. 
If, now, it could be brought about that 
more than usual should be discharged 
through the discharging opening, the ex- 
cess diet would be compensated, and 
upon further forcing of the excretion a 
decrease in the size of the body, therefore 
probably reduction, would be obtained. 

52 



OF OBESITY 

The effect might also be proved scientifi- 
cally. The remedies hasten the passage of 
nutriment through the intestines and 
thereby prevent, perhaps, good assimila- 
tion. If, however, nourishment is badly 
assimilated, then undernourishment, hence 
reduction, must make its appearance. 

To be able to eat to our hearts' desire 
and to undo this and even earlier dietetic 
sins with a cathartic tea or something of 
the sort, that would indeed be a splendid 
solution of the question ! 

It cannot be asserted that the attention 
of the public, seeking help, is not suffi- 
ciently directed to this method of getting 
the accumulated fat from the body. 
Almost every one of these preparations is 
lauded as an infallible reducing agent, 
while individual ones are characterized as 
specially invented for this purpose. 

But what is the real state of affairs? 
Hundreds of my patients have tried such 
treatments before they sought me, for 
weeks and months at a time. Even then 
a successful case could only be recorded 
when a suitable diet was followed at the 
same time. Purgative remedies alone re- 
mained without effect. A decrease in 

53 



DIETETIC TREATMENT OF OBESITY 

weight was not observed. Only during 
the first days a diminution in weight, de- 
pending upon the withdrawal of water, 
appeared. At times it seemed to the 
patients as though fat had disappeared 
in spite of that. Such statements deserve 
no credence. They rest upon agreeable 
self-deception. A reduction of fat worthy 
of consideration in healthy men must also 
be expressed in weight. Only in cardiac 
or kidney aif ections could it be concealed 
by the appearance or growth of oedema. 



54 



CHAPTER V 

Before I go on to describe the pro- 
cedure I observe, I must mention some 
other methods which have the reputation 
of efficiency with the laity and also often 
with physicians. 

The first to be mentioned is the sweat- 
bath. There are often detailed debates 
before I succeed in convincing veteran 
frequenters of the steam or of the Russian 
baths that these forms of baths, the agree- 
ableness or other usefulness of which I do 
not wish to dispute, are impracticable as 
reducing agents.^ 

The myth of the reducing property of 
sweat-baths can be traced to two false con- 
clusions. Heavy physical work draws 
forth sweat and consumes fat. Hence the 
assumption probably arose that sweating 
is the cause of the disappearance of fat, 
and that, therefore, fat could be removed 
also by sweating not produced by work. 
As is well known, however, the connection 

^ Von Noorden and Umber agree Avith nic in this 
resjiect. 

55 



DIETETIC TREATMENT 

is to be explained as follows. In muscular 
work, chemical energy is transformed into 
mechanical. Mechanical energy arises 
from the oxidation of fat and other con- 
stituents of the body. Only a part of the 
transformed energy appears again as mass 
movement (propulsion of the body, drag- 
ging or raising of burdens, etc.) ; another 
very considerable part appears as heat. 
The heat produced in excess, and which 
is an undesired by-product, leads to a rise 
in the blood and body temperature of 
the individual working. However, the 
sweat-secretion is a form of automatic 
heat-regulation intended to bring the 
heightened temperature back to the nor- 
mal point through evaporation. 

The second false conclusion depends 
upon a wrongly interpreted observation. 
The patient has lost two kilogrammes in 
weight in the electric-light bath. In a 
single hour as much as in two weeks of a 
diet treatment ! A pity that this decrease 
in weight is not permanent! Two days 
later, before the beginning of the next 
bath, the weight is recorded, and it shows 
that the two kilogrammes are back again. 
This process is repeated again and again. 



OF OBESITY 

Even at the end of such a long sweat 
treatment a real decrease in weight based 
upon loss in fat cannot be found unless 
other influences had cooperated at the 
same time. 

The false conclusion consists in con- 
founding the decrease in weight with a 
decrease in fat. Only water is lost in the 
sweat-bath (aside from slight quantities 
of tissue-change refuse which do not come 
under consideration here), but no fat is 
sweated off. The water is again equal- 
ized in a very short time by the increased 
consumption, stimulated by the heightened 
thirst, or by means of the limitation of the 
excretions through nerves and skin, and, 
indeed, with unalterable certainty. Only 
when the water content of the organism 
is pathologically augmented, especially in 
dropsy of the subcutaneous cellular tissue 
and of the body cavities, can the abstrac- 
tion of water by sweat procedures become 
successful in high degree — yes, even save 
life and bring about a permanent reduc- 
tion of the body weight, increased by the 
excess of water. These processes have 
nothing in common with the reduction of 
obesity. It is not improbable that a sweat- 

57 



DIETETIC TREATMENT 

bath, just as a hot- water bath, restricts 
the oxidative processes by storing up heat, 
and hence does not promote but hinders 
reduction. 

In spite of that, there are two cases, 
differing according to their nature, in 
which a combination of obesity treatment 
and sweat-baths is indicated. 

(1) In obese subjects, who also suiFer 
from dropsy, the latter may be caused by 
disturbances of circulation or kidney dis- 
ease. Often enormous decreases in weight 
are attained when the patient is reduced 
and at the same time the liquid output is 
increased. Here loss of water and loss 
of fat total up together. 

(2) In men who are forced, by reason 
of their profession, to exhibit a certain 
weight on certain days and at a certain 
hour. These are the riders in horse races, 
especially jockeys, whose very existence 
depends upon their not exceeding at the 
hour of the race a certain very low weight, 
the weight assigned to a particular horse. 
Less " training " than in the case of the 
latter is demanded of gentlemen riders, 
although their chances in the race depend 
not in least measure upon their weight. 

58 



OF OBESITY 

Drivers and trainers of trotting horses 
must also not be too heavy. I once assisted 
a trainer indirectly to great successes, 
which were denied him in previous years, 
by reducing his weight 15 Kg. 

An aviator weighing over 100 Kg. also 
claimed my help, because he felt that his 
weight was an obstacle to the practice of 
his sport. I have not seen him since, there- 
fore I do not know whether he observed 
the treatment, still less whether he derived 
any benefit from it. 

It is demanded of professional jockeys 
that they reduce their weight to improb- 
able degrees. They are chiefly men of 
small stature. However, the weight at 
which they " ride " is in no wise propor- 
tional to the length of their bodies. There- 
fore their muscular system, especially that 
of the arms and thighs, must be very 
powerful. Now jockeys submit to a 
training which aims at reduction of 
weight, which has been duly sanctified by 
an old tradition. The procedure consists 
in following a certain diet, chieflj^ meat 
with little drink, and in addition in 
manual labor and sweating processes. Tlie 
muscular work is generally an endurance 

59 



DIETETIC TREATMENT 

run of great extent in very warm clothing 
(sweater) . Thus a great deal of sweat is 
abstracted. On the day of the race the 
steam bath is sought and perspiration is 
promoted so far by special artifices that 
the body weight is forced down two kilo- 
grammes more. This procedure is re- 
peated every racing day, since in the mean- 
time the weight has again risen by the 
amount of the sweat lost. After the race 
the thirst is quenched and the water 
equilibrium restored. 

Now, I have tried to replace the tortur- 
ing training by dietetic methods. I had 
the good fortune to find a very suitable 
subject. One of the best — as many assert, 
the best jockey of the Vienna course — 
had the courage to break with the cus- 
tomary way of removing the winter fat 
and to entrust himself to my care. 

He attained his end without trouble, 
without deprivations and tortures. His 
weight sank from 64.9 Kg. (with clothes) 
to 57 Kg. in five weeks. 

However, the steam-bath before the 
race, by which he removed two kilo- 
grammes more, was still used. 

This case proves that the procedure 

60 



OF OBESITY 

which I followed, as compared to the old 
traditional one, does not entail disad- 
vantages which may express themselves in 
decreased efficiency in a calling which 
makes so powerful demands upon mind 
and body. The man might indeed have 
become weak or nervous. Now my jockey 
has, during the year in which he entrusted 
himself to me, excelled, as regards suc- 
cessful professional activity, not merely 
his colleagues and his earlier achieve- 
ments; he has, if I am not mistaken, 
established a record of 99 victories in one 
year. He also seems to be satisfied, since 
he came back the next year and asked for 
my prescription again. 

A second very " famous " jockey, who 
could not get rid of a surplus of 2 Kg. by 
the usual training, asked my advice. As 
I afterward learned from his owner, he 
was actually able to reduce his weight 
1.5 Kg. 

Here, also, where the result may de- 
pend upon the reduction of weight down 
to the attainable minimum, sweat-baths 
are indispensable. From the cases men- 
tioned concerning trainers and jockeys, I 
found that it is possible to carry out even 

<61 " 



DIETETIC TREATMENT 

such extreme obesity treatments without 
those tortures which men and youths who 
practise these professions have had to 
undergo hitherto. 

Further, massage belongs to those pro- 
cedures which have a reputation for effi- 
ciency, but which are not recognized by 
myself and other experienced physicians. 
It would indeed be fine if fat could be 
taken off by pressing and kneading, as 
water is pressed out of a wet sponge. 
This seems plausible to the laity. Massage 
is and has been undertaken millions of 
times to reduce fat. Even among my 
patients there were very many who had 
themselves massaged for a long time. 
Without exception, experience contra- 
dicts its efficienc}^ Simple massage with- 
out the support of other remedies never 
brought the disappearance of fat in its 
train. Nor is such a thing to be expected 
theoretically. 

The utility of another kind of massage, 
however, is, as a matter of course, even 
for me, unquestionable. I also find it in- 
dispensable as a substitute for the absent 
active muscular exercise, so far as this 

62 



OF OBESITY 

stimulates the circulation, also as a remedy 
for intestinal inertia, rheumatism, and 
many other morbid conditions. 

There is only one strictly limited indica- 
tion for massage for reducing purposes 
which deserves a trial. 

Our patients often express the wish 
that the fat be removed first and most 
thoroughly from special places. In one 
case it is the breasts, in others the ab- 
dominal walls, the neck, the hips, the 
double chin, etc. In general it can be 
promised and predicted that the effect of 
treatment will make its appearance first 
and most generously where there is the 
greatest need — that is to say, where the 
masses of fat are greatest. The large 
belly in particular, when it is caused by 
accumulation of fat in the abdominal 
walls and in the mesentery, and does not 
depend upon relaxation of the abdominal 
wall and meteorism, always vanishes 
quickly. The fact that during the treat- 
ment the stomach and intestines are less 
completely filled, and that distended feel- 
ing, about which the numerous heavy 
eaters among our patients frequently 

63 



DIETETIC TREATMENT 

complain, vanishes, exerts a supporting 
influence. 

The wish to reduce more quickly in cer- 
tain places has always seemed to me well 
founded in many cases, and I have en- 
deavored to give it its due. Whether 
successfully I cannot say definitely, since 
the attempts in question date from a very 
recent time. I believe that my supposi- 
tions are correct. They are as follows: 
The importation and exportation of fat 
to and from the stations can only follow 
the path of the circulation, probably 
through the blood and lymph stream. 
Hence if we bring it about by a suitable 
regimen that exportation must follow, and 
then reinforce the blood current in a cer- 
tain region of the body, it seems possible 
to me — yes, probable — that relatively 
more fat will be absorbed there than in 
other places. And there is probably no 
better means for stimulating the circula- 
tion than massage. When the skin itself 
is in question, electricity and hydriatic 
processes might also be considered. 

Guided by this consideration, I have 
those regions of the body massaged which 
must be reduced most quickly and thor- 

64 



OF OBESITY 

ouglily, and these alone (since otherwise 
the effect would be lessened) , and I select 
for the sessions those hours in which pre- 
sumably fat absorption ought to be the 
most active. These are the morning hours, 
before breakfast, hours which are farthest 
distant from an abundant meal, hours in 
which even in the laziest the blood supply 
is more active than at other times on ac- 
count of muscular exercise (rising, toilet) . 
As has already been mentioned, I be- 
lieve that massage alone is useless for re- 
ducing purposes. It is not improbable 
that even in the case of excess diet one 
might effect a deposition of fat in certain 
places by massage. The blood which 
carries the fat will also deposit material 
more easily where it is conducted in more 
ample quantities than in places with a 
scanty circulation. In this sense the mas- 
sage prescribed in the Mitchell-Playfair 
fattening treatment is very rational. 
Since, however, according to my convic- 
tion, most men eat too much, their situa- 
tion with respect to massage is similar to 
that of men who submit to a Mitchell 
treatment. In their case massage sup- 
ports the deposition rather than the 

5 G5 



DIETETIC TREATMENT 

absorption of fat. This is corroborated 
by experience. 

Among the remedies which have the 
reputation of effecting a reduction, iodine 
and its preparations occupy a prominent 
place. I have never seen a successful re- 
sult which was brought about by iodine 
alone. Xews of that sort of successful 
cases was always inaccurate and could not 
be verified. 

It seems that iodine through its effi- 
ciency in goitre and enlarged lymph- 
glands acquired the reputation of also 
being able to cause other organs and tis- 
tues to disappear; likewise, fat and, espe- 
cially, over-large mammary glands. 

It is well knoA\Ti that the employment 
of iodine can produce or arouse Basedow's 
disease in individual men of exceptional 
susceptibility, and that then emaciation 
sets in. This would be a bridge between 
iodine and emaciation. However, this 
possibility seems terrifying enough to me 
to avoid iodine as an auxiliary remedy in 
obesity treatments, even in its external 
application. Only when a direct indica- 
tion for iodine medication itself exists, as 

6Q 



OF OBESITY 

for example in lues and in many cases of 
arteriosclerosis, do I consider its combina- 
tion with obesity treatment permissible. 

Very lately two more proposals for 
obesity treatments have come to light. 

(1) Faradization of the muscles with 
the help of special apparatus for the pur- 
pose of increasing tissue-change. This 
process lasts an hour every day. It is 
said that the renunciation on the part of 
the patient of active muscular exercise 
makes the method possible even for the 
indolent and lazy. 

This enrichment of the " means of 
treatment " by a new, complicated ap- 
paratus may be considered in the case of 
institutions. However, I do not like to 
require my patients to procure it, because 
I am sure that the increase of consumption 
brought about in this way, as in every 
other instance, will be very easily equal- 
ized by a surplus of nourishment and its 
therapeutic effect destroyed; further, be- 
cause I consider the voluntary activity of 
the muscular system incomparably better 
than this makeshift, and because, even for 
educational reasons and with regard to the 
time after the end of the treatment, I 

67 



DIETETIC TREATMENT 

exert all my influence to insert at least 
an hour's muscular exercise into the daily 
work of the patient. 

(2) The proposal of Kaufmann 
(Halle).- Proceeding from the convic- 
tion that obesity is based upon a disturb- 
ance of oxidation (an assumption which 
is not proved), he injects a colloid solu- 
tion of lanolin in liquid paraffin into the 
fat of the abdominal walls. Thus an in- 
creased activity of the oxidative processes 
is sought. 

The injections are repeated from every 
fourteen days up to twice a week. After 
injection, fever appears. (Highest tem- 
perature observed, 40.2° C. per rectum.) 
When no fever occurs, the decrease in 
weight is lacking. An infiltrate is formed 
at the point of the injection. 

" The best results," he says, " are at- 
tained by a combination of the metal 
treatment with a Marienbad diet-cure. 
The latter does not become superfluous 
because of the remedy, but it becomes even 
more successful in many cases." The 
remedy does not protect against relapses. 

^Miinch. med. Wochenschr., 1913, No. 10. 



OF OBESITY 

The experiences given here in the form 
of extracts have not led me hitherto to 
attempt the method, for two reasons : 

(1) Because I always accomplish my 
purpose by diet and regimen alone ; and 

(2) Because I have not yet been able 
to convince myself of its absolute harm- 
lessness. 



CHAPTER VI 

As stated at the beginning, neither an 
historical nor an extensive critical discus- 
sion of the methods practised by other 
2)hysicians is to be attempted in this book. 
I only wish to inform my readers how I 
manage to reduce my patients, why I pro- 
ceed as I do, and, finally, why I do not 
use other methods. 

I have noted in the previous chapters 
that reflection and disappointing experi- 
ence have led me to employ diet as the 
supporting pillar of the whole structure.^ 

No obesity cure without dieting. Only 
by dieting is success always attained. 

Forced by circumstances, I have several 
times carried out the treatment success- 
fully with patients confined to bed, hence 
with tissue-change materially reduced. 

I by no means scorn the physical means 
already mentioned and still to be men- 
tioned. Exercise in the open air, gym- 
nastics, sport reasonably pursued, and 

^ All authors who have been successful in obesity 
treatments have reached the same conclusion. 
70 



DIETETIC TREATMENT OF OBESITY 

the cold bath, keep the body healthy, 
the mind in a happy mood. That they 
also promote tissue-change I welcome 
as a desired accompanying phenomenon. 
But their great significance lies in their 
general hygienic advantages. These lead 
me to recommend their use with modera- 
tion and discretion, with regard to the 
necessity of the individual case, to all ask- 
ing my professional advice. So also to 
obese subjects. We will return to this later. 
I am guided by the following princi- 
ples in drawing up a regimen for my 
patients : 

(1) Avoid injury. 

(2) Individualize strictly. 

(3) Impose no more deprivations than 
are absolutely necessary. 

Before I enter into details I must make 
an important confession. I have pro- 
ceeded empirically^ and have not been 
guided exclusively by the theory of 
nutrition. 

My patients receive the diet which 
brings about the daily reduction of the 
body weight by a certain fraction. In 
otherwise healthy men, this fraction 
amounts, as a rule, to from .15 to .2 per 

71 



DIETETIC TREATMENT 

cent, in a day, hence, in a man weighing 
70 Kg., about 1 Kg. per week. Only in 
very exceptional cases do I consider an 
acceleration of the rate permissible ; often, 
on the contrary, a retardation imperative. 
In youthful individuals, also in compli- 
cated cases, I frequently content myself 
with a daily decrease of .1 per cent., hence 
.50 Kg. a week in a weight of 70 Kg. 

Since the treatments are, almost with- 
out exception, carried out at home, time is 
at my disposal in unlimited or almost un- 
limited amount, and I can set my goals far 
away without endangering the health of 
my clients by forced treatments. 

My rich experience has taught me that 
that rate (with the exceptions which, as 
mentioned, occasionally occur) represents 
the ideal. 

The task which I set myself at the be- 
ginning of each treatment has a certain 
similarity with the activity of a captain 
who must bring his ship to a particular 
goal at a time previously fixed. 

First I determine the goal and the mo- 
ment of the arrival. Suppose, for example, 
that by weighing and measuring and, ac- 
cording to the principles to be mentioned 

72 " 



OF OBESITY 

in Chapter XXVI, we intend a removal 
of 10 Kg. of fat and at a rate of 1 Kg. 
per week, hence an entire period of 10 
weeks for the treatment. 

According to principles which are dis- 
cussed below, I prescribe a diet and regi- 
men and record the result at definite 
intervals. 

In many cases I find in the first, and 
especially in the particularly important 
second, record that the decrease in weight 
is proceeding at the rate desired. Then 
the regimen remains unchanged. In 
other cases the record reveals the fact that 
we are advancing too quickly; then, in 
spite of the protest of the patient, happy 
over our success, the course is retarded. 
In other cases, however, progress is too 
slow. Very rarely it happens that no prog- 
ress has been made, or even that the 
patient is heavier than at the beginning. 
In the last three cases mentioned a care- 
ful investigation must be made to find 
out whether the causes of failure or in- 
sufficient progress are due to improper 
directions or to the deficient observance of 
proper directions. 

According to the result of these investi- 

73 



DIETETIC TREATMENT 

gations5 either the diet is changed or an 
effort is made to attain a greater con- 
scientiousness in the observance of the in- 
structions by influencing the patient. He 
is also taught that infrequent, even if 
greater, deviations cause less injury than 
frequent and small transgressions. The 
latter lead, almost without exception, to a 
standstill in the weight, or even to an in- 
crease, thereby causing disappointments, 
self-reproaches, and discontent, while the 
success of a " sinless " week gives the 
patient the exalted feeling of being a hero, 
and spurs him on to perseverance in the 
treatment. 

The systematic steering for a goal is 
only possible when a record of the weight 
can be made at sufficiently short intervals. 
Patients who are conveniently near must 
visit me every week, while those living- 
farther away must send weekly reports. 
The family physician draws up the reports 
of those whose health is not quite beyond 
doubt. 

These visits or reports give an oppor- 
tunity to undertake corrections in the pre- 
scription, to review the general condition 
of the health, to change the plan of treat- 

74 



OF OBESITY 

merit, especially so far as the rate of 
progress is concerned. There are cases, 
though rare, in which the patient is not 
fitted for the treatment for reasons which 
cannot be ascertained at the first exam- 
ination. Although the deprivations which 
I require are easy to bear, indeed are 
scarcely felt as restricting by a man with 
the normal development of those mental 
qualities which are commonly designated 
as character, there are men of whom 
almost nothing can be demanded in this 
direction. When normal men report a 
slight, easily endurable sensation of hun- 
ger, the latter announce unendurable, 
ravenous hunger, which, according to 
their opinion, must be followed by the 
severest complications, cardiac weakness, 
and collapse, if not satisfied. They have 
never tried to overcome the " ravenous 
hunger," because they do not think they 
are equal to the danger involved. 

In an institution we can venture to give 
such men further treatment. If not, I 
must advise them to give up the treatment, 
perhaps to postpone it until they have 
become more energetic and wiser. We 
encounter these obstacles at times in 

75 



DIETETIC TREATMENT 

youthful individuals. A few years later 
they have disappeared and it is possible 
to carrj^ out the treatment without hearing 
complaints. 

The records put me in a position to give 
attention to the wishes and troubles of the 
patients as they appear. By small 
changes in the prescription it is almost 
always possible to take the edge from 
severities which we ourselves cannot sus- 
pect, even with the greatest experience 
(because they are not felt by other men) . 

All these reasons cause me to hold fast 
to the principle of designating the record- 
ing visits or reports as the conditio sine 
qua non of every treatment. I would con- 
sider it a gross professional error to draw 
up an obesity regimen for a man, unknown 
to me, on the basis of a single conference 
and examination, however thorough it 
might be, and then to dismiss him and not 
to trouble myself further as to the pro- 
gress of the treatment. This could 
actually be injurious. For example, if the 
weight decreased too rapidly, and the 
treatment should not be stopped in time, 
very material harm might be done. 

76 



OF OBESITY 

If success fails to appear in the first or 
second week, because of misunderstand- 
ing of the prescription or because of dishes 
prepared in a manner opposed to the 
treatment, no difficulty arises in teaching 
the patient, who has remained in touch 
with his physician, or in assisting him by 
altering the prescription. After a few 
days or weeks the man who is left to him- 
self gives up an unsuccessful treatment 
and believes that he can no longer be 
helped at all. 

There are especially " sly " and saving 
men who do not present themselves even 
one single time to the physician, but under- 
take the treatment with the help of a pre- 
scription, borrowed somewhere. In this 
way, as we can understand, the most por- 
tentous blunders occur. 

Thus in one instance the very busy hus- 
band of one of my patients, a man 180 cm. 
in height and weighing over 100 Kg., kept 
up for a week the same diet as his wife, 
who was 152 cm. in height and weighed 
70 Kg. and who was almost inactive, with 
the result that he lost about 3 Kg. in a 
week, but thereby weakened himself so 

77 



DIETETIC TREATMENT OF OBESITY 

much that he was obHged to give up his 
work for some time. 

It is a matter of every-day experience 
for me to hear about treatments, ostensibly 
ordered by me, that have resulted dis- 
astrously, when closer investigation shows 
that I have never seen the patients. In 
most cases a borrowed prescription formed 
the basis of the treatment. Those who 
lend prescriptions ought to know they are 
not doing their friends a service. 



78 



CHAPTER VII 

At first glance it might seem that the 
empirical method, the details of which are 
to be discussed more explicitly later, must 
have a poorer foundation than the method 
which prescribes every meal, every dish 
on the basis of its caloric value. I believe, 
however, that in the latter case we are 
confronted with many unknown and 
variable quantities, and that the com- 
puted determination of the regimen in- 
volves more serious errors than does my 
method. 

The quantities which are taken into ac- 
count are : 

(1) The food requirement, computed 
on the basis of the patient's body weight, 
expressed in calories. 

(2) The caloric value of individual 
articles of diet. 

(3) The coefficient of assimilation. 
An individual's need of nutriment, as is 

well known, depends on very different 
circumstances: primarily on the body 
weight, but also on the body surface, on 

79 



DIETETIC TREATMENT 

age, on sex, on the mode of life, and on 
many other known and unknown quanti- 
ties. It has been shown that some men 
liave active and others inactive tissue- 
change. 

The caloric value of articles of diet is a 
quantity which can be determined accu- 
rately. Dishes of a certain oxidative value 
can be prepared, either by recording a test 
every time or by exact quantitative prep- 
aration. But a great physicochemical 
apparatus is needed for that, and very 
much time and trouble. It is only possible 
to do justice to this desideratum in insti- 
tutions with well-appointed laboratories 
and trained assistants. As soon as the 
preparation of dishes is left to the house- 
hold of the patient, as has almost always 
been the case in my practice, the com- 
putation of the caloric value ceases. The 
true figures differ very considerably from 
those contained in books and tables. The 
ingredients themselves, even those of 
which we would not suspect this, as, for 
example, rice, differ in their nutritive 
value. To this must be added the in- 
fluence of preparation, especially of the 
fatty content of many dishes. Prepara- 

80 



OF OBESITY 

tion according to the individual taste of 
the housewife or of the cook, according to 
the custom of the country, and according 
to rehgious observances, can bring it about 
that dishes of equal weight, which bear 
the same name, differ enormously in their 
nutritive value. For example, in Hun- 
gary, green vegetables are usually pre- 
pared wdth great quantities of fat, cream, 
and sugar, and represent, from our stand- 
point, something quite different from the 
same dishes in Vienna, or, indeed, in Eng- 
land and France. 

The water content of foods also varies 
from country to country and from house 
to house, a fact which is not unimportant, 
especially as regards the different kinds 
of bread. The fatty content of animal 
foods may differ with every mouthful. 

Therefore we are not protected from 
making great mistakes when we draw up 
a diet schedule (on the basis of the tables) 
with a definite caloric value. 

Finally, the third factor is the coeffi- 
cient of assimilation, which has been estab- 
lished for different articles of food by a 
series of observations. Even this quantity 
is variable, and, what is more, not merely 

6 81 



DIETETIC TREATMENT 

in different individuals, but also in one 
and the same individual, especially under 
the influence of a reduction treatment. 
While the patient is on an excess diet, 
doubtless the nutriment will be more 
poorly assimilated than during the treat- 
ment. The comparison of the relative 
amounts of solid excrement shows this. 
Although the diet which I prescribe con- 
tains chiefly cellulose materials, a con- 
siderable portion of which should reap- 
pear in the stools, the percentage of the 
feces is reduced much more than that of 
the nutriment. It is also probable that 
the organism, before it attacks its own fat, 
uses up the nourishment offered, up to 
the very limit. In the condition of long- 
continued, severe hunger, even substances 
otherwise indigestible are not merely 
swallowed, but probably also digested. 
The reports of Sven Hedin and other 
desert travellers admit of hardly any 
other interpretation. 

Accordingly the assimilation of nutri- 
ment during the treatment must be re- 
corded daily so that no error can be made. 

We have seen, then, that the three 
points considered fixed, which ought to 

82 



OF OBESITY 

form the basis of an obesity regimen ac- 
cording to theory, are by no means fixed. 
Therefore I prefer to introduce them into 
the equation not as " known quantities," 
fearing thus to obtain a value which devi- 
ates far from the truth for the " un- 
known quantities," that is, the amount of 
nourishment to be prescribed. 

An experienced speciahst in the nutri- 
tion of the horse, Hans Jirsik, said re- 
cently: " Chemistry is a noteworthy but 
by no means infallible adviser, and its 
directions should first be tested by practi- 
cal experience." The horse, for which 
this direction is meant, and which is fed 
chiefly on oats, hay, and chaff, and whose 
single individuals differ from one another 
much less than men, certainly is subject 
to much simpler conditions than in our 
practice. The sentence quoted has so 
much the more validity for men, since we 
have to reckon here with the greatest indi- 
vidual differences, with healthy and dis- 
eased digestive organs, and with an im- 
mense number of articles of diet, which 
are differently prepared in every house- 
hold. Leyden expresses the same thought 
with reference to fattening treatments in 

83 



DIETETIC TREATMENT 

these words : " For it is a question of the 
effect, not of the dogmatic-physiological 
calculation." 

I do not wish to fall into the error of the 
" Banting treatment." In it reduction is 
attained by the supply of a nutriment 
which contains enormous quantities of 
meat and almost no carbohydrates and 
fats. Thus severe injuries to the health 
were frequently observed. But I give 
my patients more albuminous food (at 
least 1 gramme to 1.1 gramme per kilo- 
gramme of normal weight) than is neces- 
sary, in order to satisfy their nitrogen 
requirement. 

The circumstance that my patients re- 
main permanently in good health, even 
when the treatment lasts months, and re- 
tain their full bodily and mental effi- 
ciency, is most eloquent testimony that 
they are exposed to no albumin hunger 
(of the organism). 

It is the custom for a considerable frac- 
tion of the Vienna population to under- 
take on Sundays and holidays a more or 
less extensive mountain trip. In this con- 
nection it is often a question of very con- 
siderable demands on the muscles. There 

84 



OF OBESITY 

were several enthusiastic tourists among 
my patients who continued this fine sport 
with my consent even during the treat- 
ment. Their judgment of the influence 
of the treatment upon the efficiency of the 
body was unanimous to the effect that 
they felt stronger and consequently de- 
sired to increase the length and difficulty 
of the trips. I permit only young men 
with strong muscles, trained in mountain 
climbing and winter sport, with sound 
heart and normal blood-pressure, to in- 
dulge in trips which are longer than a 
simple walk of several hours. The treat- 
ment and the decrease in weight are not 
to be promoted in that way. I allow an 
increase in the nutriment for the extra 
exertion. An increase of 15 Gm. of bread 
and 10 Gm. of meat per walking hour has 
proved to answer the purpose. However, 
every sort of ''athletic achievement" is 
forbidden during the period of treatment. 



85 



CHAPTER VIII 

As already mentioned, I have en- 
deavored to bring about the decrease in 
weight at a certain rate, vrhich experience 
has shown to be harmless. I have also 
stated that I consider a decrease in weight 
of .15 to .2 per cent, in a day as the ideal. 
Now, it will be objected, with apparent 
justification, that I first prescribe and 
only subsequently learn the result; that 
at the time of beginning the treatment I 
do not even possess the basic principles 
by which I claim to be guided. At the be- 
ginning of my activity there were actually 
such difficulties, and I believe that it will 
be not without interest if I give a further 
description below of how I mastered them. 

To-day, of course, such an abundance 
of experience is at my disposal that I can 
find in my memory, or, if this should fail, 
in my carefully-kept records for each new 
patient a case which is very similar to his, 
the regimen of which is tried first. Muta- 
tis mutandis, modifications are always 
necessary. The division of the day for 

86 



DIETETIC TREATMENT OF OBESITY 

meals, the other habits of hfe, the direc- 
tion of the patient's taste, and many other 
circumstances should be regarded. I do 
not believe that two entirely identical 
prescriptions have ever left my hands. 

It is just this attention to the individu- 
ality of the patient which makes it possible 
for me to reduce the disagreeable features 
of the treatment to a minimum. 

The regimen of the " analogous case " 
forms the basis of the prescription, in 
which changes are then made which are 
often insignificant from the standpoint of 
the theory of nutrition, but important and 
decisive from that of the patient. 

Thus I generally succeed in hitting the 
mark approximately, even in the first pre- 
scription. At the next record the cor- 
recting and filing begins. The invalid 
feels a prick here and there. For ex- 
ample, he wants one of the meals in- 
creased at the expense of the others. Or 
he desires a special prescription for Sun- 
day, or for days on which he attends the 
theatre. Or he recollects a favorite dish, 
of which he is especially fond, which is 
lacking in the first prescription and which 
he painfully misses. 

87 



DIETETIC TREATMENT 

One might believe that at the expiration 
of the first week of treatment a full in- 
sight could be gained as to whether the 
prescription is correct. Indeed, we now 
have at our disposal a result, from the 
size of which we can measure whether the 
decrease is proceeding at the right rate. 
This supposition does not always prove 
true. In the transition from the old to 
the new mode of diet there is, almost with- 
out exception, a jump in the weight, the 
size of which depends not alone on the 
composition of the regimen, but also on 
the previous diet, which, as a rule, has 
not been correctly estimated quantita- 
tively. 

In about 75 per cent, of all cases the 
decrease in the first week of treatment is 
about one and a half times as large as in 
the following week; in 20 per cent, it is 
much larger. Often it amounted to as 
much as 5 Kg., in 4 per cent, it is equally 
large and in 1 per cent smaller than in the 
second and third week. 

This rare exception often remains un- 
explained. Many times in women the 
cause is to be found in the occurrence of 
the menstrual period. Often before the 

88 



OF OBESITY 

patients came to me they had followed a 
regimen which quantitatively, especially 
as regards the consumption of liquids, 
was more strict than my own. 

An extremely large majority of pa- 
tients come to the treatment after a stage 
of excess nutriment. On the previous 
days and also on the day at the beginning 
of the treatment (with me they appear in 
the afternoon), they have consumed much 
greater quantities of solid and liquid food 
than on the days of the treatment. The 
contents of the stomach and intestine are 
therefore much more abundant and heavy 
at the first weighing than after the ex- 
piration of the first days of treatment, 
during which the excess liquid and the 
food residues from the " pre-treatment " 
period have been expelled. The decrease 
in weight in the first week of treatment is 
totalled up from two factors: the loss of 
fatty tissue and the difference in the 
weight of the stomach and intestinal con- 
tents. However, these latter quantities 
can amount to several kilogrammes, espe- 
cially in men who have been accustomed 
to drink with their copious meals huge 

89 



DIETETIC TREATMENT 

quantities of alcoholic or non-alcoholic 
beverages. 

The second recorded weight gives us 
the first information about the time effect 
of the treatment. The attention of the 
patient, who is delighted by the great suc- 
cess of the first week of treatment, must 
be called to the fact that it can not con- 
tinue at the same rate. We must also 
avoid the deduction that, because the first 
week has proved a great success, we are 
entitled to increase the diet. We would 
be much disappointed at the result of the 
next weighing. Often it occurs without 
our interference. The patient thinks over 
his case and, contrary to our prediction as 
to the slight success of the next week, 
arrives at the conclusion that one need 
be by no means so particular about fol- 
lowing the prescription, since the fijst 
week has brought a very large loss of 
weight. He thinks that a decrease of 
1 Kg. will probably take place even with 
a somewhat more abundant diet. Result : 
at best a standstill in the weight, generally 
a slight increase. 

Many patients attempt, earlier or later, 
to determine whether the continual de- 

90 



OF OBESITY 

crease in weight is not an accidental coin- 
cidence with the observation of the regi- 
men, and whether it is really necessary to 
stick absolutely to the directions. They 
commit transgressions which they consider 
harmless. The next weighing teaches 
them better. 

Herbert Spencer asserts that a child 
does not learn to fear fire until it is 
actually burned. Relating the dangers of 
fire, he says, is no substitute for the ex- 
perience. Therefore the child is allowed 
to feel the pain of a slight burn, by not 
being prevented from getting one, and it 
is thereby given an important experience 
for its whole life. I have followed this 
rule from practical pedagogy with my 
patients. I do not warn them overmuch 
about " sins of treatment," and I am not 
sorry to see them find out the consequences 
of their disobedience for themselves. 

I wish now to indicate briefly the way 
which led me to my first experiences about 
the amounts of nutriment which are nec- 
essary in order to gain a definite daily or 
weekly result. 

If a man is weighed at short intervals, 
let us say hourly (we can let him sleep 

91 



DIETETIC TREATMENT 

during the night), and the weights are 
recorded in a table or curve, we find a 
course of dail}^ deviations in weight which 
follows a law and is determined by defi- 
nite influences. Such systematic weigh- 
ings were first carried out in 1561 by San- 
tario, born at Capo d'Istria, and led to the 
important discovery of insensible per- 
spiration. 

Every time a man eats, the body is 
increased by the weight of the meal ; every 
emptying of the bladder or intestine de- 
creases it by the weight of the matter 
expelled.^ 

Aside from this, however, the weight 
also sinks continually, as Santario dis- 
covered. According to Rubner, the ex- 
cretion of water- vapor through skin and 

^ Laymen are accustomed greatly to overestimate the 
significance of the emptying of the intestine on the 
weight. The weight of the scanty stools, which are 
generally observed during the treatment, ought only 
exceptionally to reach 100 Gm. (the normal stool weighs 
100 to 200 Gm.). To be sure, these losses can amount 
to several kilogrammes in diarrhoea. Here there are 
losses of water from the blood and tissues which are 
very quickly equalized by more abundant drinking when 
recovery begins. Hence when a movement of the bowels 
does not occur on the day of recording, this fact can 
affect an insufficient weekly result only very slightly. 
Constipation of several days' duration, to be sure, might 
give rise to quite respectable increases in weight, 
92 



OF OBESITY 

lungs (the cause of the steady decrease in 
weight) amounts to 60 Gm. an hour when 
the body is resting, and as much as 125 
Gm. an hour during vocational work. 
Hence in a day this makes at least 1.5 Kg. 

Now, these different influences bring 
it about by their cooperation that the 
minimum weight appears immediately 
before dinner, the maximum immediately 
after dinner. (Perhaps this rule only 
holds in those countries where, as in Aus- 
tria and Germany, the chief meal is eaten 
at noon in middle-class circles.) 

Therefore the weight is not, as one 
might believe, lowest in the morning be- 
fore breakfast. The slight increase, 
which is due to the light breakfast cus- 
tomary with us, is much more than com- 
pensated by the urinary secretion, which 
is especially abundant during the morn- 
ing hours, and by the insensible perspira- 
tion of the hours from 6 to 8 a.m. 

The maximum and minimum weights 
are, hence, only separated by dinner. 

It is now quite clear that the maximum 
weight can he voluntarily regulated with- 
in certain limits. 

By varying the size of the noon meal 

93 



DIETETIC TREATMENT 

I can keep the maximum weight within 
two Hmits. One Hmit is identical with the 
minimum weight, the weight before the 
meal, and would be reached if I should 
place the dinner at 0, — in other words, 
omit it; the other would be obtained by 
a dinner of maximum weight. Hence I 
would have to direct the patient to eat 
and drink as much as he could. But I 
choose a middle course, as will be shown 
in a constructed example. Let the patient 
to be reduced in weight weigh on the first 
day of the treatment 89 Kg. as his mini- 
mum. I give him now 1 Kg. of food, 
therefore, for example, 200 Gm. of soup, 
120 Gm. of meat, 180 Gm. of vegetables, 
100 Gm. of farinaceous food, and 300 Gm. 
of water. The maximum weight of this 
day is then 90 Kg. 

The plan is now to reduce the maximum 
weight by 1 50 Gm. every day. On the next 
day the patient is weighed before dinner. 
He is given enough food to bring his 
weight to 89.85 Kg. On the eleventh day 
of the treatment the maximum weight 
can amount to only 88.50 Kg. and at the 
expiration of 100 days to only 75 Kg. 
Thus the rapidity of the decrease — the 

94 



OF OBESITY 

most important factor of all — would be 
brought entirely under the control of the 
physician and regulated in the simplest 
manner. The patient could be assured 
that on a certain day, not earlier and not 
later, he would attain a certain weight. 

The considerations which oppose these 
methods, which I admit are grossly em- 
pirical, I have not suppressed. What hap- 
pens if the minimum and the maximum 
weight do not run parallel — if, for ex- 
ample, the patient on the succeeding days 
remains equally heavy before dinner? In 
that case he would have to eat less and 
less for dinner ; on the sixth or seventh day 
nothing at all. But then this could go 
no further, because the minimum of the 
day would be higher than the maximum. 
Therefore, in order still to carry out direc- 
tions, we would have to advise the patient 
to give out food instead of taking it. 

I have considered these difficulties well, 
but have not been dissuaded from making 
the trial first on myself. 

In this connection some rules had to 
be followed. Three meals were given 
daily : breakfast and supper as uniform as 
possible with regard to quantity and com- 

95 



DIETETIC TREATMENT 

position of the dishes ; both meals modest 
in their nutritive values, so that room may 
be spared for a more abundant third meal. 
This third meal, the variable dinner, 
should give the key to the influencing of 
the weight. Further, since drinks in- 
fluence the weight as well as solid foods, 
care must be taken that the quantity of 
water consumed, from awakening until 
dinner, remain constant. In the afternoon 
and evening the drinking of water was 
permitted, since the urinary secretion 
efl'ects the equalization. Dishes which 
cause strong thirst were avoided. 

The determination of the size of the 
dinner was made in the following manner. 
A coordinate system was drawn on milli- 
metre paper. Ordinates: weights, ab- 
scissse: time. On the first day of the 
treatment, after a moderate dinner, the 
first " maximum " was determined. It 
amounted to about 90 Kg. I wished to 
weigh 80 Kg. 10 weeks later. Both 
points were looked up in the coordinate 
system (90 Kg. on the day and 80 Kg. 
on the 70 day), and joined by a straight 
line. The minimum weight was deter- 
mined before dinner of the second and of 



OF OBESITY 

each following day; and entered on the 
curve. The vertical distance of this point 
from the line of the maocimum weight 
determines the weight of the dinner for 
the day. 

To my joyful surprise it appeared 
now that the line of the minimum weight 
ran almost exactly parallel with the line 
of the maocimum weight. In other words, 
when we reduce the maximum weight, 
which is in our power, a definite amount, 
kept within reasonable limits, the mini- 
mum and all other weights, also the weight 
on the morning of the following day, sink 
almost the same amount. (This circum- 
stance was purposely ascertained.) 
Therefore there remained every day be- 
tween the maximum and the minimum 
weights an interval which kept almost the 
same, which corresponded to a dinner 
sufficient to appease the hunger ** accord- 
ing to the treatment." (The subsequent 
computation of the oxidative value gave 
1200 to 1400 calories per day. The 
albuminous content amounted to 90 to 
100 Gm.) 

The lines did not run exactly parallel. 
They converged a little. Accordingly as 

7 97 



DIETETIC TREATMENT 

time advanced, the dinner had to be 
limited a little. This procedure is also 
well fomided in the theory of nutrition. 
The need of nutrition becomes slighter 
with the decreasing body weight. The 
diet necessary to maintain the individual 
approaches more and more a definite low 
diet. The deficiency of nutriment be- 
comes smaller and corresponding to it also 
the decrease in weight. But if it is 
desired, as in our case, to attain daily 
equal decreases in weight, the quantities 
of food must be gradually lessened.^ 

Nothing would be easier than to carry 
an attempt of this sort ad absurdum. If 
the amount of food provided for dinner 
should be composed of dishes of espe- 
cially high nutritive value, and hence 
should yield much fat and little water, the 
next day would probably bring no de- 
crease in w^eight or no sufficient one. And 
if we were still to cling to the principle, 
the next dinner would become very scanty 
or be omitted entirely. All conditions 

^ I consider it more expedient not to restrict the diet 
with the advance of the treatment so long as this is 
possible, but rather to hazard a relapse of the rapidity 
of the reduction in weight. 

98 



OF OBESITY 

must be exactly followed which promise 
a success for the treatment. 

The noon meal contained a constant 
amount of liquid in the form of water and 
soup, besides a constant amount of meat. 
The amount of the other dishes was varia- 
ble: vegetables, also potatoes, farinaceous 
foods and fruit. No bread was eaten. In 
the first two or three days the decrease 
was very large; it depends, as already 
mentioned, not exclusively on the loss of 
fat. When this is repeated in the future, 
it is not to be recommended to enter these 
days in the tables and curve. 

I have carried out such attempts in fif- 
teen patients of different age by deter- 
mining daily the minimum weight before 
meals and the size of the dinner resulting 
from the curve, which I then divided up 
into the different courses of the meal in 
the way which seemed to me expedient. 
Naturally it was necessary here and there 
to alter the other two meals also ( at times 
there were even three ) . Otherwise, how- 
ever, everything ran off smoothly; the 
body weight decreased precisely at the rate 
at which I had previously agreed with the 
patient. 

99 



DIETETIC TREATMENT 

I have no doubt that in this way every 
man, no matter whether his tissue-change 
is normal or abnormal, whether food is 
cooked fat or lean in his house, can be re- 
duced at a rapidity determined before- 
hand. Since the danger or the absence 
of danger of a treatment depends pri- 
marily upon this rapidity, I also keep this 
factor in my power. I can choose a rate 
which is so slow that injury can be ex- 
cluded with a probability which borders 
on certainty. Thus mistakes or errors 
are corrected almost automatically. If 
too much nutritive value is supplied in 
the weight allowed for the meal, this is 
shown on the next day or in the following 
daj^s by a too slight decrease, which re- 
quires a suitable alteration; and vice 
versa. The result of too slight nutritive 
value of the foods would be a too great 
decrease in weight and would necessitate 
its correction in the sense of an addition 
of caloric supply. 

The difference between the procedure 
which I observed and the apportioning 
out of nutriment according to calories 
can, perhaps, be illustrated by a com- 
parison. A steam engine is to be kept in 

100 



OF OBESITY 

operation. I insert an almost automatic 
regulator, which immediately cuts off the 
supply of fuel when the motor makes 
more revolutions than is desired, and 
which supplies more abundant fuel when 
the number of revolutions decreases. 

But there is also a different procedure. 
It can be computed from the oxidative 
value of the coal, standing for the time be- 
ing at our disposal, from the quality of the 
flue, the amount of the material unoxi- 
dized, which passes off with the smoke, 
from the loss of heat of another sort, etc., 
and the degree of efficiency of the ma- 
chine, how much coal per day and hour 
must be burned up in order to attain a 
definite number of revolutions, — that is 
to say, the accomplishment of a certain 
amount of work. Since, however, all 
these values are usually only approxi- 
mately correct, and because every ma- 
chine has its individual peculiarities, even 
changes from day to day; so, finally, the 
performance of equable work by the ma- 
chine can not be attained without regula- 
tion according to the result. 

But in the case of men individual differ- 
ences are much greater than in machines, 

101 



DIETETIC TREATMENT OF OBESITY 

and the principles upon which the theory 
of nutrition is constructed are by no 
means so well established as the theories 
upon which the construction and the 
operation of our heat motors are founded. 
On that account I have made regulation 
according to result, the basis of my 
method,^ 

^ The calculation of the diets prescribed showed that, 
according to the individuality of the patient, from 800 
to 2000 calories were necessary in order to attain the 
result desired. 



102 



CHAPTER IX 

As already mentioned, only in fifteen 
cases was the supply of nutriment varied 
daily to correspond to the result of the 
weighing. Thus I gained the first experi- 
ence regarding the approocimate quanti- 
ties of nutriment which must be given 
differently constituted men in order to 
gain a certain daily or weekly decrease in 
weight. Later I contented myself with- 
out exception with weekly weighings and 
directions, which remained in force for 
a week. This makes no essential differ- 
ence. With the experience which is at my 
command I generally strike the right 
course approximately. And if I make a 
slight mistake in either direction, no harm 
can arise from it in the course of a week. 

I exercised caution in the daily direc- 
tion of the composition of the menu, 
either undertaking it myself or leaving it 
to the patient within certain limits. I 
allow him, for example, less of a nutritious 
vegetable than of one less nutritious, or 
less of a farinaceous food with a higher 

103 



DIETETIC TREATMENT 

caloric value, consisting only of dough, 
than of one which produces fewer calories 
in the unit of weight, which, for example, 
also contains fruit {" Nudeln-Apfel- 
strudel''), I prescribe now daily equal 
quantities by weight of single courses, so 
that the average of their nutritive value 
is the deciding factor. Thus the direc- 
tion becomes simpler, the computation 
easier and more certain. There are fewer 
mistakes. 

The capacity of a meal to satiate de- 
pends, as already mentioned, not, or at 
least not primarily, upon its caloric value, 
but upon the weight and, especially, the 
volume of its solid constituents. Liquids 
are not counted; they are removed from 
the stomach in a direct way. We can not 
satisfy the appetite with water. 

Now, since the satisfaction of the feel- 
ing of hunger must indeed be heeded, I 
prefer to recommend such foods as have 
a low specific weight, — that is, which 
possess a large volume for a certain 
weight. When patients from Austria are 
under consideration, I recommend them 
for this reason to eat frequently boiled 
beef for dinner, because this has a much 

104 



OF OBESITY 

greater volume for the same weight than 
meat dishes cooked in fat or broiled. One 
hundred and twenty grammes of boiled 
beef form a bulk which is greeted by most 
men as the usual — often, indeed, as an 
unusually large — portion, while a piece of 
roast beef or beefsteak of the same weight 
appears small and disappointing. 

Boiled beef is also rightly considered 
that meat dish which is least injurious to 
sufferers from gout. Both properties of 
boiled beef which we have just discussed 
are of importance in the not rare combina- 
tion of gout and obesity. Pity that this 
food, which also furnishes a tasty soup 
as a by-product, and which is eaten by all 
classes almost daily in Austria, is hardly 
known in most countries of the civilized 
world, or at most serves as food for the 
servants ! 

The wish to fill the patient's stomach 
without supplying him with greater 
quantities of actual nutriment causes me 
to make abundant use of some foods 
which might be designated as " ballast " 
food. To this classification belong cucum- 
bers, also varieties of green salad, pre- 
pared with little oil, or, still better, without 

105 



DIETETIC TREATMENT 

oil, besides radishes and black radishes, 
asparagus, artichokes, but, above all, 
fruit. Among the kinds of fruit which I 
prefer there are again: apples, especially 
sour kinds, and berries (currants, called 
ribisel in Vienna, and strawberries). 
Apples can be enjoyed eight months in 
the year and are relished by an exceed- 
ingly large majority of men, and contain 
but little nutritive value: 100 Gm. = 50 
calories. Their sugar content amounts to 
7 per cent, or still less. Pears, plums, 
cherries, oranges are also permitted in 
corresponding quantity. Grapes contain 
for the most part as much as 15 per cent, 
sugar. Hence, compared to apples, they 
must be granted in smaller quantity. In 
autumn grapes belong to the dangerous 
seductions of the table. Many men who, 
from fear of becoming fat, never put a 
lump of sugar (weighing 5 Gm.) in their 
coffee eat confidently day after day one 
kilogramme of wine grapes (they allege 
that grapes "give no nourishment"), 
whose sugar content alone amounts to 150 
Gm. (600 calories), hence is equal to 30 
lumps of sugar. 

I never cease calling attention to the 

106 



OF OBESITY 

fact that the nuts, rich in oil, almonds, also 
the " Southern fruits," deficient in water 
but rich in sugar, may not be substituted 
for an equal weight of apples and pears. 
But the principle otherwise holds good 
also for the varieties of fruit mentioned, 
and for some others, which I do not like 
to recommend (melons, mandarins) . No 
food is absolutely forbidden; each one may 
appear in the limits of a diet in a certain 
quantity. No food is unrestricted. Let 
every one be measured out. The quantity 
is determined by the scales. 



107 



CHAPTER X 

Eating according to measure and 
weight is first found in the method of re- 
duction which was devised by W. Harvey, 
described by Harvey's patient, Banting, 
after whom it was named. Since then it 
has formed the foundation of all sensible 
treatments of this kind. 

But while many writers reserve quanti- 
tative nutriment according to the scales 
only for certain more serious cases, I take 
the ground : without scales no cure. Even 
when there is but little fat to be removed, 
we cannot do without the scales. I owe 
my complete absence of failures primarily 
to adherence to this principle, 

I found no serviceable scales for deter- 
mining the weight of the food. The bal- 
ance scales with weights are entirely un- 
suited, because determining the weight 
would demand far too much time and 
attention. 

Only spring-scales are adapted to our 
purposes. But some important altera- 
tions must be made in them before they 
correspond to all demands. In place of 
the hollow and generally too small metal 

108 



DIETETIC TREATMENT OF OBESITY 

dish, we must put a flat plate upon which 
any vessel we want can safely stand. But 
the most important alteration consists in 
the net weight apparatus which I first 
introduced. 

It is troublesome and tiresome to weigh 
the plate first, then food and plate to- 
gether, in order to compute the net weight 
by subtracting the first number from the 
second. Many men require for this 
mathematical accomplishment paper and 
pencil, others indeed work out the calcula- 
tion in their heads, but are so absent- 
minded and forgetful that they do not 
notice the weight of the plate, are, there- 
fore often forced to place the foods on a 
second plate in order to determine the 
weight of the first plate again. Still 
others make wrong computations and 
thereby endanger the success of the treat- 
ment. 

These different " cases " are not in- 
vented, but experienced. Therefore I had 
to hasten to seek radical remedies, if the 
eating according to the requirements of 
the scales was not to fall into disrepute as 
being too complicated and one which 
makes the dishes cold and unen joy able 

109 



DIETETIC TREATMENT 

because of the great amount of " weigh- 
ing and calculating." 

There are two food scales which I have 
invented. The older, less perfect one, an 
improvisation, has two pointers, one 
firmly fixed to the axis, and one recog- 
nizable by a varying form and color, which 
can be turned upon its axis with some 
friction. Now the weighing is done in 
the following manner: The vessel in- 
tended to hold the food is placed upon the 
scales, the fixed pointer is pressed against 
the dial plate with the thumb of the right 
hand, while the movable pointer is pushed 
around to zero with the fingers of the left 
hand. Then the food is placed upon the 
plate. Its weight is read off from the 
movable pointer. We would expect that 
this simple process could be carried out by 
every one without error. Experience 
showed, on the contrary, that two mis- 
takes which are grave under certain cir- 
cumstances are committed. For example, 
because of an inexact fixing of the immov- 
able pointer, the movable pointer, when 
the other is released, does not stop at zero, 
but deviates to one side or the other. The 
second mistake is based upon the fact that 

110 



OF OBESITY 

the decisive pointer is not near enough to 
the dial plate, so that incorrect readings 
are possible because of wrong position of 
the eyes. The eyes must be exactly in 
the prolongation of a perpendicular which 
is drawn from the tip of the pointer to 
the level of the dial plate. Incorrect read- 
ing alone can easily account for mistakes 
of 20 Gm., and the total of both mistakes 
for mistakes of 40 Gm., which would de- 
feat the purpose of the weighing. 

Very recently I succeeded in construct- 
ing a net-weight food scales which greatly 
excels the one just described in regard to 
simplicity of manipulation, and which 
absolutely excludes errors in weighing. 

The new scales (Figs. 1, 2, 3) has only 
one fixed pointer, which revolves close to 
the dial plate, so that parallactic errors in 
reading no longer come into consideration. 
The deduction of the weight of the vessel 
is rendered possible hy the fact that the 
dial 2)late itself can be revolved. 

The process of weighing is as follows: 
The dish (bowl, glass) is placed upon the 
scales; the dial plate is revolved with the 
help of the peg A until its zero point is 
covered by the pointer. Then the food is 
111 



DIETETIC TREATMENT OF OBESITY 

placed upon it. We can read the weight 
directly from the pointer. If a second 
food is to be placed upon the same dish 
and weighed, for example, vegetables with 
meat, then the dial is^rst turned to the 
pointer until this stands again at zero, and 
its weight is read off directly after the 
second food is placed upon it. The three 
illustrations show (1) the scales before 
the beginning of the weighing; (2) with 
the weight of the plate deducted; and (3) 
after the food has been placed upon it. 

A suitable portion of solid foods is 
selected and weighed off on the plate 
already deducted. We add or subtract 
from it until the directions are satisfied. 
Soups and other liquids are carefully 
poured in until the pointer arrives at the 
correct place. 

The weighing should be exact to 10 
Gm. As I have ascertained by trials, it 
requires a period of ten to fifteen seconds, 
hence not more time than is at the disposal 
of even the hastiest.^ 

* The new food scales which bear my name are 
manufactured by the wagon and machine factory, C. 
Schember and Sons, in Vienna and Budapest, and can 
be obtained in the warehouses of this firm and from 
dealers in surgical instruments and apothecaries. 
112 



CHAPTER XI 

Most of the invalids who seek my advice 
breathe a sigh of deUght when I inform 
them that they may take water or mineral 
water in any quantity during the treat- 
ment. The fear of thirst obviously pre- 
vents many men from attempting an 
obesity treatment. Many cannot be 
brought to believe that fat can be lost 
without suffering thirst, and some per- 
suasion is often needed to convince them 
of the complete untenableness of the 
opinion that water is one of the most 
dangerous fattening agents. This belief 
is general, although the most experienced 
physicians in this field, as Von Noorden 
and Ebstein, combat it as a superstition 
exactly as I do. As the last-mentioned 
author has ascertained, the prescription 
to bring about a reduction by non-drink- 
ing goes back to Pliny the Younger. A 
French physician, named Dancel, sought 
to cure complicated and uncomplicated 
obesity by thirst treatment in the sixties 
of the past century. This procedure be- 

8 113 



DIETETIC TREATMENT 

came generally known in Germany and 
with us through Oertel and Schweninger. 
My experiences, however, which, as men- 
tioned, fully coincide with those of Von 
Noorden and Ebstein, convincingly teach 
that it is superfluous to make a man thirst 
for the purpose of losing fat. 

The limitation of the supply of water- 
which without exception causes more tor- 
tures than hunger, should be stricken from 
the list of the iwrmitted means of reduc- 
tion. 

Agreeing with Von Noorden, I believe 
that only indirectly can thirst display an 
effect, since it destroys the appetite in 
many men. When the patients are not 
permitted to drink at will they do not 
relish their meals, and it may happen that 
for a while they eat less than is necessary 
for maintaining the body weight at the 
same figure. 

The organism's poverty of water which 
must appear in the first days of a thirst 
treatment naturally diminishes the body 
weight, and this loss of weight may in 
the case of topers — there are also water 
topers — amount to several kilogrammes. 
Naturally it has nothing in common with 

114 



OF OBESITY 

reduction. As soon as the men in ques- 
tion thoroughly quench their thirst again 
the weight rises to the earher height in 
a very short time. 

I do not limit the supply of water merely 
because I consider thirst an entirely un- 
necessary torture, but also for another 
reason. 

In further agreement with Von Noor- 
den, I believe that the withdrawal of water 
is directly injurious to many (patients 
with gout, sufferers from hepatic and 
renal calculi ) , and is able to incite attacks 
of their disease. 

Obese gouty patients, who had previ- 
ously taken thirst treatments, and who, 
nevertheless, had suffered from repeated 
attacks, became unusually well and re- 
mained well for a long time under my 
regimen, in which they were not merely 
permitted but even directed to drink 
great quantities of water or mineral water. 

It is perfectly clear that we would do a 
great injury to men who are suffering 
from the excretion of tissue-change refuse 
hard to dissolve if we were to limit the 
ingestion of the principal solvent. 

Obesity treatments were considered, and 

115 



DIETETIC TREATMENT 

are considered even to-day, as inciting 
causes of neurasthenia. I am convinced 
that the prescription of a thirst regimen, 
almost universally followed some time 
ago, is also to blame for that. Not that I 
believe that it is possible to create neuras- 
thenia by such a regimen, but, indeed, I 
heard from my patients that through this 
a latent neurasthenia manifested itself in 
them. 

It may occur that, on account of other 
ailments which exist along with obesity 
(cardiac defects with oedema, contracted 
kidneys), a restriction of the supply of 
liquids must be recommended. As a mat- 
ter of course, I recognize this indication. 
But then it is the complication, not the 
obesity, which leads me to do that, and 
the restriction never exceeds the modest 
measure which at other times is appro- 
priate in these affections, and hence 
never reaches such proportions as to war- 
rant mention of a thirst treatment. 

W. Ebstein reports that the diet recom- 
mended by him as a remedy for obesity 
exercised an extremely favorable influence 
upon the abnormal thirst which torments 
many obese persons, and he assumes that 

116 



OF OBESITY 

the abundant fat which characterizes his 
prescriptions of diet exerts the appeasing 
effect. 

In the face of that I can state that also 
the diet whicli I prescribe, which, indeed, 
is not absolutely free of fat, yet contains 
but little fat, exerts this often positively 
wonderful eifect. 

In 1906 a 34-year-old merchant from 
Bohemia, who then weighed 125 Kg., con- 
sulted me. His weight during the last 
years had increased on an average of 10 
Kg. per year. Various earlier treatments 
brought only an unsatisfactory and tem- 
porary success. 

His report began with the following 
statement : " Every day I drink at least 
10 litres of water; if I were to be pre- 
vented in that I would become crazy." 
The condition for undertaking the treat- 
ment was my assurance that he could 
drink absolutely as much water as he liked. 
The man was a large eater, consumed 
great quantities of meat. His urine con- 
tained no sugar. 

A week later I saw the patient again. 
He was taken aback. From the first day 
of the treatment his abnormal thirst had 

117 



DIETETIC TREATMENT OF OBESITY 

disappeared. He drank no more water 
than many other men, about two htres a 
day. The treatment progressed accord- 
ing to schedule and lasted several months. 
The tormenting thirst did not return 
again. 

This was the most noteworthy case of 
this kind. Yet I regularly observed the 
thirst-quenching influence of the treatment 
both before and since. 

Let it be well noted : Here it is a ques- 
tion of water thirst. Beer and wine 
thirst belong to another chapter. 



118 



CHAPTER XII 

When I was a boy and passed my 
holidays on the estate which my parents 
managed, I was often glad to look on 
when the cattle were given their fodder 
and water. First came the fodder, then 
the man went with filled drinking pails 
from cow to cow, from ox to ox. At that 
time men could also drink water at will 
during their meals. 

Later the relations were reversed. It 
was found incorrect, indeed even horrible, 
that the cattle should not drink while eat- 
ing, and there were constructed special, 
ingenious arrangements with a constant 
water-level, vessels covered with lids, 
which the cattle open themselves with their 
mouths. The cow can now drink as often 
as it likes. It makes abundant use of 
this freedom. But men have been for- 
bidden, chiefly by '' nature-physicians," to 
drink during meals. 

No examination is to be made here as 
to whether or not this measure is appro- 
priate in many cases. It only interests us 

119 



DIETETIC TREATMENT 

in so far as obese subjects are often 
obliged to suffer from it. In many insti- 
tutions which are sought by the obese to 
cure their ailment the separation of food 
and drink is carried out with the greatest 
severity. As former frequenters of such 
establishments inform me, this rule is 
generally felt to be very tormenting. In 
time, to be sure, many accustom them- 
selves to it as well as to other discomforts. 

On the basis of my rich experience, I 
can assert most definitely that it is quite 
needless to subject our patients to any 
compulsion in this respect. They may 
drink water, as much and as often as they 
wish, hence also during meals. 

Drinking while eating has an especial 
charm for most men. It forms a substan- 
tial constituent of the pleasures of the table. 

Let us probe more deeply into this 
circumstance. 

As is well known, the intensity of the 
perception of every sense impression, 
which operates uniformly for some time, 
becomes dulled, often to complete disap- 
pearance. This is true of all senses, even 
of the " higher ones." Finally we are no 
longer aware of the clamor of the uni- 

120 



OF OBESITY 

f ormly clattering mill, any more than the 
intense, uniform noise which penetrates 
to our city dwelling from the street. Our 
sensitiveness to continuous stimuli of both 
" chemical " senses, smell and taste, sinks 
with extreme rapidity. 

If we enter a room, the air of which is 
contaminated by illuminating gas, we per- 
ceive this immediately, even when the per- 
centage of gas is very slight. But if the 
gas streams out steadily while we remain 
in the room, we generally detect nothing 
even when the amount of gas is so great 
that the person just entering starts back in 
fear. That is true of all smells. 

This is exactly the condition with im- 
pressions of taste. The perception itself, 
but especially the pleasurable sensation 
connected with the perception, dies out 
quickly when the same stimulus exerts 
influence longer at the same intensity. 
The interruption of the sensation by 
each act of swallowing counteracts this 
to a certain extent. At all events, each 
of us knows that the first mouthful of a 
delicious food tastes better than the tenth, 
this better than the twentieth. Men (and 
also animals), however, have found ways 

121 



DIETETIC TREATMENT 

and means to prevent this decrease of the 
pleasurable sensation. The " monotony " 
of taste perception must be done away 
with. In this direction our palate is much 
less fastidious than our ears, which, in 
order to appreciate pleasurable sensa- 
tions, require a rich succession of different 
tones. The palate is satisfied with two 
alternating " taste-tones," which must 
always harmonize, like the acoustic tones. 
Almost every food which one who has 
outgrown infancy ^ consumes with relish 
consists of at least two components. With 
coffee, tea, etc., bread or cakes are eaten, 

^ The pleasurable sensations of infants while nursing 
are, as is well known, caused much more by the act of 
sucking than by the taste of the food. The rubber 
nipple almost replaces the mother's breast for it. The 
child of three years already consumes complicated meals 
which are similar to those of the adult, even with re- 
spect to the conditions mentioned here. But between 
these ages there lies a period in which the food of the 
children of prosperous cities (in the country the child 
who has just been weaned generally eats everything 
"along with") is composed almost invariably according 
to theoretical principles of nutrition. The pleasure in 
eating, about the lack of which we so often hear com- 
plaints, might perhaps be heightened if mouthfuls of 
two different foods were given alternately; naturally, 
those which agree well in taste and wholesomeness. Now 
and then even necessity teaches people to discover this 
expedient. Recently I attended the meal of a two-and- 
a-half-year-old world-citizen. A spoonful of broth and 
a spoonful of apple sauce were given him alternately. 
As I was taught, only thus could they succeed in getting 
the child to take the sufficient amount of food. 
12£ 



OF OBESITY 

Soup almost always contains solid con- 
stituents, which taste differently from the 
liquid. With roasts, at least one side dish 
is eaten: vegetables, salad, preserves. 
Potatoes often form a component of the 
vegetable courses. 

Farinaceous foods often contain addi- 
tions of fruit or marmalades, or are eaten 
with whipped cream or fruit juices. With 
ices there are waffles, etc. There are 
always two taste tones, which are struck 
alternately. 

Frequently the two concordant notes 
are chosen so remarkably that theoreti- 
cally they must seem to be discords, al- 
though they harmonize excellently in 
practice. 

If we observe children to whom, for 
example, different tropical fruits are 
given as dainties, we see that they con- 
sume alternately an almond and a Malaga 
berry. Other examples of this kind could 
easily be found. The cigar with black 
coffee also belongs here. 

Now there are two means, which can 
almost always be attained, of radically 
interrupting the monotony of a protracted 
taste sensation and of imparting to the 

123 



DIETETIC TREATMENT OF OBESITY 

following mouthful the same zest which 
the first of its kind possessed : a drink or a 
mouthful of bread. Both of these remove 
the remains of the food just eaten from 
the gustatory papilla. If the drink con- 
sists of water, which is by no means taste- 
less when of good quality, but which can 
appear as tasteless in comparison to the 
foods, the continuity of the taste sensation 
is interrupted; there is a pause in the 
melody, and the subsequent bite is again 
relished and enjoyed as fully as the first. 
A piece of bread has a similar effect, the 
taste of which being less marked, I might 
say " neutral gray," makes a good foil 
for every other kind of taste. 

The expediency of dividing off two 
courses of a meal by a piece of bread or a 
drink in order to prevent the confluence 
of discordant taste impressions appears 
of itself after what has been said. 

We make the treatment more endurable 
for our patients if we do not designedly 
limit the maximum of the pleasurable 
sensations which their diet can afford 
them. And for the majority of men the 
drinking of water during meals belongs 
among these pleasurable sensations, 

124 



CHAPTER XIII 

Alcoholic beverages also have an 
effect similar to that of water. Besides 
the mechanical removal of the remains of 
food which is palatable, a new taste-ele- 
ment, generally very agreeable, is brought 
into play. In beer it is the bitter materials, 
the carbonic acid ; in wine, different palat- 
able and pungent constituents; in both 
beverages, above all, alcohol itself. 

None can dispute the fact that these 
beverages heighten the pleasures of the 
table; often to such a degree that a con- 
sequent incitement to abuse arises. On 
the other hand, however, there is no doubt 
that wine and beer have a harmful, or at 
least a retarding, effect upon the progress 
of obesity treatments. Alcohol is indeed 
a poison, but, as has been shown, also an 
article of diet of high heat-producing 
value. It protects a quantity of stored-up 
fat which is equivalent to it in caloric 
content from the destruction we intend. 
Other nutritive materials besides alcohol 
are contained in beer and sweet wine. 

125 



DIETETIC TREATMENT 

According to Rubner, one litre of beer 
contains as much oxidative material as 
500 Gm. of meat or 500 Gm. of potatoes. 

The abuse of alcoholic beverages could 
only very seldom be established as a cause 
of obesity in the case of the patients who 
followed my advise. 

But a false picture of the etiology of 
the disease would be formed by giving 
general recognition to my statistics in this 
respect. In places with a large consump- 
tion of beer enormously fat figures are 
seen in great number, and every child 
knows the connection between beer and 
fat belly. Conversely we could probably 
draw an inference from the average 
weight of the adult population of a city 
as to the customary use of beer there. 

Corpulent beer drinkers seldom seek 
my aid, and probably other doctors who 
are occupied with the treatment of obesity 
have the same experience. They have 
generally become indolent through alco- 
hol, and they carry their heavy burden 
with amazing carelessness. The fear of 
the prohibition of beer is greater than the 
fear of severe suifering and early death. 
The weight of their body, which limits 

126 



OF OBESITY 

their activity to a minimum degree and 
which allows them, as their only recrea- 
tion after the day's cares, to sit in the 
saloon and to continue the enjoyment of 
beer, forms an important part of the 
circulus vitiosus which threatens to de- 
stroy their lives prematurely. 

As already mentioned, I am seldom 
confronted with the problem of offering 
advice to confirmed drinkers. But I see 
the " larval stage " very often. There are 
men, generally young, who have become 
fat through a surfeit of solid food, but 
who also consider a few glasses of beer, 
wine, or cognac indispensable for main- 
taining their working power or their good 
humor. 

If they are young individuals, then I 
strike alcohol in every form relentlessly 
from their diet. I am sure that I have 
brought about many a rescue from the 
claws of this dragon. I found, also, as 
Forel and other champions of the anti- 
alcohol movement, that complete absti- 
nence is easier to attain than moderation. 
It is easier to refuse the first than the 
second glass. 

In older patients I first begin with the 

127 



DIETETIC TREATMENT OF OBESITY 

prescription of entire abstinence. The 
treatment is promoted by absolute ab- 
stemiousness. But when it cannot be 
carried out, and when the patients are 
content with small quantities of alcohol, 
I am forced by necessity to submit to 
compromises. 

I was forced to allow here and there an 
eighth, or at most a quarter, of a litre of 
light wine per day or a glass of beer on 
Sundays. 

Only once was the following prescrip- 
tion wrung from me by a gigantic young 
opera singer as conditio sine qua non of 
the treatment : Daily, half a litre of beer ; 
on days when he sang, one litre of beer. 
On Meister singer days (he sings " Walter 
Stolzing ") , one and one-half litres. Even 
in this case I succeeded in attaining a 
sufficient decrease in weight so long as 
the artist followed my advice. The beer 
forced a corresponding quantity of other 
nutriment from the prescription. 

This case forms an exception, a curi- 
osity. Otherwise, in the interest of my 
patients, I have been an opponent of 
alcohol in every form. 



128 



CHAPTER XIV 

In the search for the causes of obesity, 
I found in my patients that a certain mis- 
take in nutrition was most frequent: im- 
moderation in the consumption of bread. 
I do not think I am mistaken when I 
assume that 90 per cent of my clientele 
brought about their increase in fat in this 
way (as already mentioned, beer drinkers 
are not included in my material ) . 

In order to obtain the knowledge I had 
to call attention to this point in ascertain- 
ing the history of the patient, and I did not 
allow myself to be satisfied by evasive 
answers. When one of our patients is 
required to describe his previous mode of 
nutrition in every detail, we can bet a hun- 
dred to one that he forgets to name the 
bread in the noon and evening meal. There 
is no intentional reticence in this, hence no 
act which would be charged so severely 
against the witness in court, as untruth.^ 

^ It is diverting but also interesting from a psychologi- 
cal standpoint to observe how the patients never omit 
to report at this examination everything which they 
do not eat. " In the morning nothing," " no soup," " no 
potatoes," " tea without sugar." Merely tea always 
means tea with sugar, cream, rum, etc. Only a closer 
inquisition brings these details to light. 

9 129 



DIETETIC TREATMENT 

Eating bread at the table follows almost 
automatically, without the participation 
of the cerebral cortex, as the alternating 
advancing of a leg in walking. This is 
begun even before the soup. Every one 
thinks it necessary to eat bread with fish 
or other dishes. The roast, so many be- 
lieve, canot be eaten at all without bread; 
especially the fat sauces require bread as 
a side dish. Bread is eaten between the 
courses, and bread, butter, and cheese 
must form the conclusion of the richest 
dinner. 

As is well known, the bread consumed 
in the Austrian restaurant is paid for, it 
must therefore be reported how much 
of it has been taken. Let the observer 
note how often the diners have no idea 
of how much they have eaten. 

In 1905 a report came to me from a 
southern city of our empire, first by let- 
ter, then personally, that all three children 
of a family had become abnormally fat 
without discoverable cause. The eldest 
son, 16 years old, weighed 116 Kg.; the 
second, 11 years old, 98 Kg.; an eight- 
year-old girl, 80 Kg. 

Inquiry as to the mode of nutriment 

130 



OF OBESITY 

was answered as follows : In the morning 
coffee is drunk; in the afternoon soup, 
meat, vegetables, farinaceous foods are 
eaten ; in the evening cold meat, preserves, 
and salad; not more of any of these than 
others are accustomed to eat. All kinds 
of sport, especially cycling, were prac- 
tised abundantly. 

I considered it advisable to go to the 
bottom of the matter personally, and, for 
this purpose, I participated in all the 
meals of the family for a day. Now a 
sufficient explanation as to why the chil- 
dren put on fat was revealed. The oldest 
boy ate daily at least two kilogrammes, 
often even more, of a dry wheat bread 
which contained but little water; the two 
others at least one and one-half kilo- 
grammes of it. 

The quantity of bread, 4800 calories in 
one case and 3600 in the other, might have 
sufficed alone, without any other food, to 
bring about an intensive addition of fat 
in the three children. 

This is probably my most striking case. 
I have no certain knowledge of it, be- 
cause only in very exceptional cases was 
I in a position to record with the scales the 

131 



DIETETIC TREATMENT 

food which the patient chose himself. 
Heavy consumption of bread is, however, 
admitted by the overwhelming majority 
of my patients (to be sure, often only 
after searching inquisition) . And among 
the few who assert that they eat Httle 
bread, there are certainly individual cases 
who thereby deviate from the truth with- 
out perhaps knowing it. 

There were many among my patients 
who did not exactly live in luxury, and it 
can be understood that these fattened 
themselves with one of the cheapest foods. 
But I was surprised when I could deter- 
mine that even the most wealthy of all, 
almost without exception, only put on fat 
because they were immoderate in the con- 
sumption of bread. 

It was demonstrated in an earlier chap- 
ter that bread is especially adapted to 
bring the sense of taste, if I may call it 
that, down to zero and to make it as sus- 
ceptible to every following mouthful as 
though it were the first of its kind. By 
interspersing mouthfuls of bread, a larger 
quantity even of rich and fat food can be 
eaten with enjojrtnent. Fat sauces, for 
example, urgently require bread to make 

132 



OF OBESITY 

them palatable. We will see that my 
patients, if only for this reason, have to 
give up fat sauces. 

Besides, bread belongs to the few foods 
which can be eaten daily and hourly, of 
which we can not '' overeat." 

Bread is perhaps the only solid food 
which can be eaten in a large quantity in 
connection with butter and cheese, even 
upon a full stomach, without the appear- 
ance of repugnance or disgust. 

Guided by the endeavor not merely to 
cure my patients but also to guard against 
relapses, I find that I am induced in the 
majority of cases to eliminate the use of 
bread during the two chief meals. As an 
article of food rich in carbohydrates, 
bread, theoretically, is to be judged no 
differently from many other foods of 
similar composition, but in practice, ac- 
cording to my experience, it is the most 
dangerous to our patients, because an 
excess of it is eaten altogether too easily, 
and because it leads to more of other, 
especially fat, foods being eaten than is 
permissible and beneficial. 

An excessive consumption of meat is 
also spoiled for many if they are not 

133 



DIETETIC TREATMENT 

allowed to eat bread at the same time. In 
this way we succeed in satisfying men who 
have this inclination with the portion of 
meat which is proper, even when it is sub- 
stantially smaller than the accustomed 
one. 

Naturally, there would be no difficulty 
in finding a place in every prescription for 
a small amount of bread for the noon and 
the evening meal. But I consider it more 
correct, especially in the case of the numer- 
ous obese people who previously ate a 
great deal of bread, to accustom them to 
absolute bread abstinence, because success 
with this, exactly as in the case of alcohol, 
is easier to attain than educating them to 
be temperate, and because I attach espe- 
cial importance to disaccustoming them 
ever after from eating bread with the 
chief meals, and thereby eliminating the 
most important cause of the renewed 
fattening. 

Exceptions occur in the cases in which 
the household provides cold meat every 
evening. It would be terrible to forbid 
absolutely the side dish of bread, which is 
always customary with cold meat and 

134 



OF OBESITY 

which is difficult to replace by anything 
else. 

Many men eat only cold meat in the 
evening once or twice a week. I am ac- 
customed to allow a corresponding 
quantity of bread for such days. 

I permit almost regularly a small 
quantity of bread (30 to 80 Gm.) to be 
a constituent of the first breakfast. This 
is not so dangerous as eating bread at the 
chief meal. If the patient has been ac- 
customed to eat his first breakfast with- 
out bread, he continues to do so. He is 
recompensed for it at other meals. 

The nutritiveness — that is to say, the 
caloric value of the bread — varies a little 
according to the material from which it is 
prepared. Wheat bread (100 Gm. = 265 
calories) is more nutritious than rye 
bread, the latter again more nutritious 
than pumpernickel (230 calories) and 
than a variety of the latter, the so-called 
" simonsbread," esteemed by many. But 
the differences are not large enough to 
have any weight in the small amount of 
bread which I allow. Hence the patients 
may choose the kinds of bread which 
taste best to them, and perhaps even vary 

135 



DIETETIC TREATMENT 

them in the course of the treatment, or 
from day to day. 

Let mention still be made of a wide- 
spread prejudice which, as we saw, is so 
frequent in our subject. 

The consumption of fresh rolls (white 
rolls) is tabooed in obesity. On the other 
hand, toast or zweiback is considered 
harmless, perhaps even useful. Again 
and again I hear the complaints of the 
patient, innocently punished: " I have 
become fat in spite of the fact that I eat 
only toast and never fresh rolls." 

I often have trouble in inducing the 
patients to eat fresh (that is, untoasted) 
bread (the weight determined by the pre- 
scription), in spite of the fact that they 
prefer the latter because of its superior 
flavor. An expedient can be found for 
those who cannot be taught and for those 
who prefer toast by allowing them to toast 
the bread which has just been weighed. 
Equal parts by weight of fresh and 
toasted bread vary substantially in their 
nutritive values. Toast (the caloric value 
of 100 Gm. amounts to about 360) is 
more nutritious than fresh bread, since 
in toasting a loss of water is eff'ected, 

136 



OF OBESITY 

which is significant, but which varies ac- 
cording to the method of toasting. The 
nutritious constituents are in part made 
more easily assimilable and are better 
used up by the dextrinization of the 
starch. 

The fear of water extends, as it seems, 
even to the water in bread, which must 
then be driven out by toasting. In view 
of the very small quantities which enter 
into question, it is even more foolish 
than the " hydrophobia " which opposes 
drinking. 



137 



CHAPTER XV 

Those inclined to obesity ought to limit 
the number of their meals to a minimum 
during the treatment and also later, hence 
their whole life long, or at least so long as 
the inclination to put on fat is present. 

Not all physicians agree on this point. 
Many recommend more frequent, lighter 
meals. 

My personal experience and that of the 
most intelligent of my patients cause me 
to stick to the principle: Few meals — 
three, at most four, in a day. I believe 
that my standpoint also has a theoretical 
foundation, and I will attempt to show 
this here, although I actually attach im- 
portance only to the result of the practical 
test. 

If animals are to be fattened, food is 
supplied them as frequently as possible. 
The chemical work which the organs of 
digestion represent is kept in continual 
operation in the daytime; at times even 
night shifts are added. Many physicians 
follow a similar procedure in fattening 
men. 

138 



DIETETIC TREATMENT OF OBESITY 

As soon as the stomach is emptied or 
can be considered emptied, new food is 
introduced, and in the selection that kind 
is preferred which quickly leaves the 
stomach. Thus digestive disturbances 
may arise which demand the interruption 
of the fattening process for several days. 

The technic of infant feeding has 
undergone a powerful reform in the last 
two decades, exactly in the point which 
occupies us here. It is very probable 
that this reform has a considerable share 
in the huge decline in infant mortality, 
and thus also in the enormous decline in 
the total mortality of the population of 
all civilized countries. 

While formerly the child was fed with 
the breast or with the bottle as often as 
it expressed its discontent with its situa- 
tion by crying, the number of daily meals 
is now restricted by all child specialists to 
six, five, indeed, in some circumstances, 
to four, and the observance of sufficiently 
great intervals between the meals in the 
daytime, and of a very long pause, lasting- 
all night, is stated to be a very important 
requirement in this question, which is so 
important to all humanity. The result of 

139 



DIETETIC TREATMENT 

this measure was that the failures in rear- 
ing, which end very frequently in the 
death of the child, became less frequent, 
and that the number of digestive disturb- 
ances also decreased; that, further, the 
increases in weight of the children be- 
came greater and more uniform. 

The restriction of the number of meals 
is certainly not the only cause of the lower 
infant mortality. The more frequent en- 
forcement of feeding at the mother's 
breast, as well as the advances in the prep- 
aration of artificial food, — on the one 
hand, asepsis; on the other, more suitable 
modification, — has also contributed to this 
result. Then, too, hygienic and thera- 
peutic achievements, which have led to the 
diminution of the mortality from tubercu- 
losis and diphtheria, have contributed, as 
well as the correct distribution of the 
infant's meals. The result (which will be 
recognized at some time in the future as 
the greatest achievement of our time, truly 
not lacking in advances) has been the re- 
duction of the total mortality by about a 
third of its earlier amount. 

The stomach of the infant is not to be 
filled again before the preceding meal 

140 



OF OBESITY 

is expelled. Even this alone does not 
suffice. There should be an interval be- 
tween two meals in which the stomach is 
empty, unoccupied. Even for this organ 
periods of activity should alternate with 
periods of rest, as is provided in Nature 
for every living creature. Plants have 
their physiological rest; the nervous sys- 
tem of animals is refreshed by sleep. Even 
the heart has its pause for rest during the 
diastole. 

Therefore I cannot resist the impression 
that the fattening treatment, with its con- 
tinual demand upon the digestive appa- 
ratus, with meals following one another 
in rapid succession, represents a process 
which is contrary to the laws of Nature, 
and which is more adapted for geese (who 
on that account fall sick of a fatty liver 
so palatable to us men) than it is for men, 
whom we wish to make not merely heavier 
but also more powerful and healthier and 
more capable of resistance. 

In the Appendix of this book it will be 
shown that I actually succeeded in a con- 
siderable number of cases in carrying out 
successful fattening treatments without 
frequent meals and without the other 
compulsory measures which are gener- 

141 



DIETETIC TREATMENT 

ally felt by those to be fattened as very 
disagreeable. 

According to my opinion, in fattening 
treatments only three, or at most four, 
meals should be allowed, of which, how- 
ever, onty two consist of several courses: 
above all, for pedagogical reasons. Not 
a small number of our patients was ac- 
customed to insert extra meals, to eat 
" something " in the morning, generally 
not little, and also to develop afternoon 
tea into an abundant meal. There are also 
some who take liquids (beer!) or solid 
foods late in the evening. These frequent 
eaters must be taught during the period 
of treatment to get along with few meals, 
since otherwise, at the end of the treat- 
ment, and after the cessation of medical 
supervision, they would eat their complete 
fill five or six times a day, which is more 
dangerous, under all circumstances, than 
if they do this only twice a day. 

Many patients have already remarked 
themselves that it is better to be content 
with few meals. Still others have eaten 
only three times a day since they submit 
to the regulation of the household to 
which they belong. To prescribe new 
meals for these would certainly be absurd. 

142 



OF OBESITY 

Only rare exceptions remained in which 
I was forced to deviate from the rule. It 
was a case of people, almost without ex- 
ception men, who, by virtue of their call- 
ing, were not in the position to observe 
the meal hours in general use; that is to 
say, who had the first large meal (noon 
meal) so far removed in time from the 
first breakfast that it would hardly have 
been feasible to refuse them a lunch at ten 
or eleven in the morning. 

The objection will now be made that the 
sensation of himger can be more easily 
banished by frequent than by infrequent 
meals. My experience contradicts this. 

The sensation of hunger appeared with 
wonderful regularity at the hours at 
which a meal was taken on the previous 
days. 

I myself am accustomed to take nothing 
between dinner and supper, and I feel, 
at the time at which many other men 
drink tea, absolutely no desire for food. 

But when I take on two consecutive 
days (one day is not enough) tea with 
sandwiches, etc., on the next day I am 
reminded of the fact at five o'clock by a 
very substantial hunger that tea ought to 



143 



DIETETIC TREATMENT 

be drunk now. Two days without tea 
suffice to restore the old status again. The 
desire for food no longer appears in the 
afternoon. 

It is probable that many men have had 
the same experience. I know some who 
wake up at a certain hour at night, tor- 
mented by hunger, and take food, gener- 
ally only a mouthful. A colleague, who 
had become undernourished as a result of 
disease, went so far in this respect that 
he consumed a complete meal, consisting 
of meat and several other courses, in the 
middle of the night between two periods 
of sleep. 

I easily succeeded in weaning him from 
this, and in bringing him to adopt a more 
reasonable division of time for his meals, 
with much improvement in his health. 

Nothing IS easier than to accustom 
adults and children (this is well known 
of infants) to a certain new division of 
meal hours and another order of meals. 
The sumptuous first breakfast of the 
Englishman or American, consisting of 
meat and other things, is probably the first 
of the national customs which the German, 
who is much less exacting about his meals 

144 



OF OBESITY 

in the morning, adopts when he goes to 
England or America. It cannot be the 
chmate which stimulates the appetite so 
early in the morning, for the climate of 
the eastern part of the United States is 
totally different from that of England, 
but the abundant breakfast in both places 
is pretty much the same. 

Habit, custom, and occupation deter- 
mine when and in what division the total 
of the food which is at the disposal of the 
individual is to be consumed. 

I seldom found difficulty in eliminating 
superfluous meals. After from three to 
four days the patient became accustomed 
to the new order, and thereby an advan- 
tage was generally gained, which was of 
benefit even after the cure was complete. 

Not a few of the heavy eaters among 
my patients before commencing the treat- 
ment suffered from various digestive dis- 
turbances ( of which mention will be made 
in Chapter XX). I ascribe the fact that 
these troubles were almost always removed 
not in least measure to the restriction of 
the number of meals and the observance of 
sufficient intervals between meals. Not 
only the infant's stomach, but also that of 

10 145 



DIETETIC TREATMENT 

the adult, should be filled again only when 
it has gotten rid of the previous meal. 

The " normal " meals of my patients 
comprise: A breakfast, consisting of tea 
or coffee, some bread (with or without 
butter) . When circumstances permit, one 
or, in exceptional cases, two eggs are 
added. Then dinner, consisting of several 
courses, and supper, which is more simply 
observed, yet which contains a meat dish, 
a side dish, fruit, and often still other 
" ballast " food. Polish and Russian 
patients like to eat, several evenings a 
week, only sour milk with bread or pota- 
toes. This also makes a very commend- 
able evening meal for the period of treat- 
ment. If there is an urgent desire for a 
cup of tea in the afternoon, it is granted. 
But a sumptuous meal with many rolls, 
cakes, sweets, etc., may never be taken at 
this time. Two or three Albert or similar 
cakes must suffice as a " bite " with tea. 

I have had an experience with coffee 
which does not harmonize with the pre- 
vailing theory. It is usually taught that 
unsweetened black coffee possesses no 
nutritive value, and hence may be allowed 

146 



OF OBESITY 

quite indifferently and as freely as water. 
I have often tried this and have often been 
obliged to retract the prescription. The 
decrease in weight progressed better when 
little coffee or none at all was consumed. 
But there are very many cases in which 
the success is not disturbed by a cup of 
Mocha. 

As already mentioned, a departure must 
frequently be made from the rule in the 
division of meals. Individualizing ex- 
tends even to this point of the regulation 
of the treatment. 

In many countries the greatest part of 
the population take their chief meal in 
the evening. Lunch is there a simple, 
" picked up " meal. Even with us and in 
Germany this order of meals is followed 
in many circles. 

From the standpoint of the theory of 
nutrition, the conceptions of the small 
meal and of the large meal do not, to be 
sure, coincide with the sense which is 
generally ascribed to these words. The 
amount of nutriment does not depend 
upon the number of courses but upon the 
character and quantity of the foods of 
which the meal is composed. A breakfast 
of bread and meat may represent a more 

147 



DIETETIC TREATMENT 

hearty meal than a dinner of ten courses. 

I am wont to respect the old accustomed 
usage even during the treatment. I pre- 
scribe for those who have been accustomed 
to dinner in the evening a meal which con- 
sists of several courses (soup as introduc- 
tion), and give them at noon a meal of 
simpler composition, which, however, is not 
to be inferior to the German noon meal in 
nutritive value. According to my experi- 
ence, an insufficient meal (as the treat- 
ment requires this) is better borne in the 
evening by men who are working than in 
the middle of the day. The sleep, which 
is almost invariably very deep and quiet 
during the treatment, even in patients 
who were previously dissatisfied in this 
respect, helps best over this difficulty. 
Hence, as a matter of fact, the larger meal 
is to be transferred to noon, the smaller 
one to evening. 

To be sure, there is generally no room 
for a third large meal, the English break- 
fast. I never encountered obstacles when 
I reduced the first breakfast to a modest 
measure. 

Those who do no serious work all day 
and who wish to keep awake late in the 
evening may be allowed the more abundant 

148 



OF OBESITY 

meal in the evening, when they themselves 
state that they feel the " greater " hunger 
in the evening. 

How far we have to depart at times 
from every pattern is shown by the fol- 
lowing case: 

No. XL, 50, a 34-year-old engineer, suffered 
in 1905—1907 from malaria in German West 
Africa. For 4 years has been in perfect health. 
Sedentary mode of life, almost no exercise, sleep 
at night 6 hours, 1 hour at noon. Inner organs 
without noteworthy findings, spleen not en- 
larged, blood-pressure 100 mm. Hg. 

The patient weighed, in 1901, 95 Kg. By a 
strict self -prescribed diet he brought his weight 
down to 90 Kg., but very quickly increased his 
weight to 98 Kg., after the conclusion of the 
treatment. He came home from Africa, weigh- 
ing 105 Kg. In 1910 again attempts at treat- 
ment : Diet, Miiller systemi of gymnastics, much 
exercise of other kinds. Temporary decrease 
to 101 Kg., then a short standstill, and recent 
increase to his old maximum weight of 105 Kg. 

Patient leaves his home early in the morning 
and comes home so late that he cannot take an 
abundant, warm meal until evening. His order 
of diet is the following: 

Seven o'clock in the morning : Coffee, two rolls. 

Ten o'clock : Double slice of bread and but- 
ter, two Zervelat sausages, often even more. 
149 



DIETETIC TREATMENT 

Three-thirty p.m.: Coffee, two rolls, and 
black bread with butter or cakes. 

Eight o'clock : Roast with potatoes and green 
vegetables, farinaceous food or cheese, much 
bread, fruit. Drink : Almost nothing but water. 
(Let attention be paid to the large amount of 
bread in the diet.) 

A radical change in the division of the day 
and the meals was excluded. Therefore I pre- 
scribed the following unusual regimen: 

Seven o'clock: 200 Gm. of coffee with milk 
(20 Gm. milk), one lump of sugar (5 Gm.), 40 
Gm. of rolls. 

Ten o'clock: 150 Gm. of Zervelat sausage, 
100 Gm. of black bread, 10 Gm. of butter, 150 
Gm. of apples or oranges, 150 Gm. of salt 
pickles, 80 Gm. of radishes. 

Three o'clock: 200 Gm,. of coffee with milk, 
one lump of sugar, 40 Gm. of rolls. 

Eight o'clock in the evening: 130 Gm. of 
lean roast or 200 Gm. of poultry roast (includ- 
ing the weight of the bones), 100 Gm. of pota- 
toes prepared without, or with only little, fat, 
140 Gm. of green vegetables (alternately 
spinach, kale, boiled lettuce, cabbage, cauli- 
flower, green beans, green peas, carrots, kohl- 
rabi, red beets), 100 Gm. of radishes, 200 Gm. 
of apples or oranges. 

Only water as a drink, but this in unlimited 
quantities. 

150 



OF OBESITY 



The man, who was 174 cm. in height, 
weighed at the beginning of the treatment 
104.90 Kg. A decrease in weight of 15 
Kg. was fixed as the goal of the treatment. 
The further progress was as follows : 



Date. 


Weight. 


Remarks. 


November 29, 1911.... 
December 6 


104.90 
102.70 

101.60 
100.40 

99.30 

99.00 

97.80 
96.30 

94.80 
93.00 

91.30 


Beginning of treatment. 

A slight feeling of hunger 
during the first days, 
later, no more. Stools 
without cathartics. Very 
much reduced in quan- 
tity. Pulse 68. Blood- 
pressure 90. 

Perfect health, no hunger, 
slight constipation; 
Apenta water prescribed. 
Blood-pressure 100. 

Euphoria. Stools again 
without cathartics. 
Pulse 68. Blood-pres- 
sure 100. 

Pulse 72. Blood-pressure 
100. One egg is added to 
the first breakfast. 

Was travelling. Ate with- 
out weighing. 

Euphoria. 

Drank milk frequently on 
account of a bronchial 
catarrh. 

Pulse 64. Blood-pressure 
90. Perfect health. 

Pulse 68. Blood-pressure 
90. Patient no longer 
keeps exactly to the pre- 
scription. 

Euphoria. Treatment con- 
cluded. Normal diet 
prescribed. 


December 13 

December 20 


December 28 


January 3, 1912 

January 10 


January 17 


February 7 


March 14 


April 15. . 





151 



DIETETIC TREATMENT OF OBESITY 

The patient has not been obhged to 
neglect his exacting calHng, even for an 
hour, during the treatment, and finds that 
the normal diet prescribed for him is a 
completely satisfying nutriment. 

I have referred to this case in more de- 
tail in order to show that the goal can be 
reached even in more difficult cases (ab- 
normal conditions of life, intricate divi- 
sions of meals, almost no exercise). 



152 



CHAPTER XVI 

Repeated mention has been made of 
the fact that a good obesit}^ treatment can- 
not be a hunger treatment in the sense in 
which laymen understand the word. Had 
my patients continuously, or indeed daily, 
been tortured many hours by hunger, they 
would not have complied with my rules 
for months at a time. 

In the oral and written report which I 
receive every week, and in which I always 
inquire after " hunger," an affirmative 
answer to this question was extremely in- 
frequent. Few, except individuals with 
weak wills, especially neurasthenics, com- 
plain of hunger. During a treatment, 
correctly conducted, men with a sound 
nervous system feel hunger, as already 
mentioned, only before the meal, hence at a 
time when hunger represents a normal, 
one might almost say an agreeable, sensa- 
tion. Only the first two or three days of 
the treatment, the transition period from 
the accustomed to the new regimen, are 
an exception. In this connection the con- 

153 



DIETETIC TREATMENT 

sideration arises that at times meals must 
be entirely omitted. As we have already 
heard, hunger appears at the hour of the 
usual meal. Further, the first meals ac- 
cording to the plan of the treatment often 
do not quite satisfy hunger. In a not in- 
considerable number of cases, on the con- 
trary, the patients report that they had not 
been so well satisfied for a long time as 
during the treatment. They also suppose 
that they have increased in weight, and 
they are very agreeably surprised when 
they see that, on the contrary, they have 
undergone a considerable decrease in 
weight. 

We can generally learn from the his- 
tor}^ which of the patients will be satisfied 
and even surfeited in the first days of 
treatment. They are the ones who them- 
selves have attempted to decrease their 
body weight, or at least to keep it at the 
same height by a diet. For this purpose 
they have reduced the volume of their food 
under the amount which the prescription 
of the treatment contains. The nutritive 
value, on the contrary, was greater than 
that which my prescription required. The 
feeling of satiety depends, however, as 

154 



I 



OF OBESITY 

already emphasized, primarily upon the 
volume of the non-liquid food, not on its 
nutritive value/ 

According to W. Ebstein, fats form an 
exception. This may indeed be correct. 
I myself and different persons whom I 
consulted with respect to this, however, 
perceived satiation with fats or very fat 
dishes not entirely as the accustomed 
normal satiation. A disagreeable after- 
taste clung to it, a more or less outspoken 
feeling of disgust, which awakens in many 
men the wish to remedy it by a glass of 
cognac, etc. 

I attach value to satisfying my patients 
in such a way that I allow them a suffi- 
cient quantity of solid foods. Since fats, 
in a certain volume and weight, represent 
more nutritive value than any other food 
constituent, and since I, as many others, 
do not recognize a special advantage in 
fatty nutrition, compared with carbo- 
hydrates, I reduce the fatty content of the 
foods to a degree which is compatible with 
their palatability, and as far as the na- 
tional or individual cuisine of the patient 

^ Milk, which coagulates in the stomach, must be cou- 
sideretl solid food. 

155 



DIETETIC TREATMENT 

allows. In particular I attach value to 
the meat foods being chosen from lean 
pieces, forbid fat sauces, try to replace 
the vegetables which are prepared with an 
excess of fat by ones with less fat. 

The great significance of " ballast '' 
food I have already emphasized in an 
earlier chapter. In a certain direction 
potatoes also belong to the " ballast " ma- 
terials. They contain, on an average, 75 
per cent, water and only about 20 per cent, 
starch, and small quantities of fat and 
albuminous bodies as nutritive constitu- 
ents. Boiled in water or salt water or 
baked without fat, they may be allowed in 
quite large quantity (100 Gm. of boiled 
potatoes yield about 100 calories). But 
when prepared differently, they generally 
contain so much fat that this, not the pota- 
toes, is the deciding factor in forming an 
estimate.^ 

This is true, and, what is more, in still 
higher degree, of vegetables, as spinach, 
kale, endives, and boiled lettuce, cabbage, 

- Very recently reference has been made to the value 
of potatoes as an article of food on account of their 
high sulphur content. Almost without exception they 
have been included in my prescriptions. The new 
investigations will confirm me in this practice. 
156 



OF OBESITY 

cauliflower, celery, kohlrabi, green beans, 
green peas, turnips, and carrots. In 
general, they have little nutritive value 
(carrots, with 6 per cent, sugar, somewhat 
more nutritious than the others). The 
nutritive value of the prepared course de- 
pends in small measure upon the kind of 
vegetables, primarily upon the way in 
which they are prepared, whether with 
fat — of which they may contain great 
quantities — flour, sugar, and cream. The 
oxidative value of 100 Gm. of spinach can 
amount to 50 or even 250 calories. 

Mushrooms, raw or preserved in vine- 
gar, belong to the constituents of our diet 
which have little nutriment. But when 
they come to the table soaked in fat, 
whereby their original water content is 
very much reduced, they form an ex- 
tremely concentrated article of diet. They 
are very well adapted to improve the taste 
of soups and sauces. 

Express emphasis must be laid upon 
the fact that, so far as the treatment is 
concerned, nuts cannot be considered fruit. 
They contain about 65 per cent, of fat and 
are articles of diet which possess the great- 
est nutritive value in the smallest volume. 

157 



DIETETIC TREATMENT 

100 Gm. of hazel-nuts correspond in nutri- 
tive value approximately to 1800 Gm. of 
tart apples. 

There are also among the farinaceous 
dishes bulky and compact foods. To the 
former belong those fermented and those 
prepared with beaten white of egg, be- 
sides the ** butter-dough " farinaceous 
dishes. 

There is always an agreeable surprise 
when patients whose diet-prescriptions 
contain farinaceous foods weigh for the 
first time cakes or tarts, prepared with 
beaten white of egg. 100 Gm. are an 
immense portion; 100 Gm. of noodles, on 
the contrary, a very modest little amount. 

In drawing up a diet schedule, we have 
to give heed to two properties of foods: 
the nutritive value, which is decisive for 
the success of the treatment, and the 
volume, which determines the factor of 
satiation. 

We know already that the sensation of 
hunger appears at certain hours. These 
are the hours of eating on the days im- 
mediately preceding. But what happens 
now when the expected meal is not given? 
Each of us has already had this experi- 

158 



OF OBESITY 

ence. The hunger does not last continu- 
ously for hours at a time. After a certain 
time, which usually amounts to no more 
than an hour, it vanishes. If the meal 
which has been skipped is still set before 
us, the appetite develops during the eat- 
ing, but does not generally attain the in- 
tensity which it otherwise possesses. De- 
layed meals are not consumed with a full 
appetite. Now, since we know that the 
appetite stands in the closest relation to 
the secretion of the gastric juice, the gen- 
eral rule follows — one which deserves spe- 
cial heed during the period of treatment 
— that the meals should be given at 
definitely established hours. 

Several times it has occurred that the 
treatment has failed on account of the 
impossibility of doing justice to this 
demand. 

I have already mentioned the fact that 
the feeling of satiation appears when a 
certain quantity of food, irrespective of 
the composition, reaches the stomach. The 
" adjustment " of the stomach can be in- 
fluenced in either direction by education 
and habit. Heavy eaters feel satiated only 
when they can eat no more — when the 

159 



DIETETIC TREATMENT 

stomach is tightly filled. After some days 
of treatment, however, the feeling of satia- 
tion appears earlier — that is, when the 
stomach is less filled. Moreover, it ap- 
pears in a more agreeable form. Satiety 
*' enough to burst " is accompanied by un- 
pleasant sensations of tension, frequently 
even by belching.^ 

Training the stomach to temperance in 
the amount of food is a gain to the patient 
for all future time. He feels happy in the 
consciousness of being able to be agree- 
ably satiated even with less quantities than 
before. 

According to my experience, from 600 
to 700 Gm. of solid food are enough to 
satiate a large and powerful man at dinner. 
In the case of small, delicate women the 
amount may, and often must, be reduced 
to 400 Gm. With our German order of 
meals the stomach is more easily satisfied 
in the evening, and two-thirds of the 
amount stated suffices to banish hunger. 

It is important to know the following 
fact. Even when the feeling of satiation 

^ In China, and, as I recently read, also in Albania, it 
is considered an insult to the host, a proof that the 
guest has not relished the meal, if he does not belch 
after eating. 



OF OBESITY 

is not present at the conclusion of a scanty 
meal, it appears with certainty a few 
minutes later. A cigar or a cigarette helps 
many past the critical moment, which de- 
mands the exertion of some will-power. 

But there is still another means of get- 
ting past this dangerous period: the pro- 
longation of the time of eating, which, 
however, must not consist in the extension 
of the pauses between the single courses^ 
but in the extension of the time which 
every single course demands for its dis- 
posal. This is attained by chewing every 
mouthful long and thoroughly. I might 
not, indeed, be wrong if I assumed that 
even before Hippocrates physicians 
urgently recommended to their patients 
thorough chewing of food. The proverb, 
" Well chewed is half digested," is very 
old. Nevertheless, a special impetus was 
still needed to bring chewing into 
" fashion." It is now called " Fletcheriz- 
ing," and is the constituent part of a 
" system " which the American, Fletcher, 
discovered. 

Fletcherizing consists mainly in spitting 
out every mouthful after " its soluble con- 
stituents have been extracted " by long 

11 161 



DIETETIC TREATMENT 

chewing. Liquids must also be chewed. 
Thereby Fletcher gains absence of smell 
and substantial reduction of the mass of 
the feces, so that his followers are obliged 
to go to stool only once or twice a week! 
Defecation must occur in squatting posi- 
tion; this also belongs to Fletcherizing, 

The choice of foods must be left to the 
taste of each individual, strengthened by 
education. Fletcherizing is said to have 
as a result a cure of the " morbid appe- 
tite " {'' Esssucht '"'), and a strengthening 
of the organism. 

I have had no experience with sys- 
tematic Fletcherizing, and no occasion to 
observe it. I have never tried or per- 
mitted spitting out food. But one thing 
I find correct. Long and thorough chew- 
ing of food brings about a quicker appear- 
ance of satiation. A feeling of fatigue in 
the cheek muscles is associated with the 
feeling of satiety. The resolution to end 
the meal is thus made easier. 

By prolonging chewing, we eliminate 
the dangerous pause, already mentioned, 
between the end of the meal prescribed 
by the treatment and the appearance of 
satiation. This influence of " partial 

162 



OF OBESITY 

Fletcherizing," as we will call thorough 
chewing, in order not to give up the woo- 
ing power of the fair name, will make the 
observance of the treatment prescriptions 
easier for many large eaters. 

According to Pawlow's investigations, 
meat broth belongs to the most effective 
stimulants of the gastric secretion. Soup 
as the first course of a meal therefore 
stands in its proper place, even considered 
from the physiological standpoint. 

But now soup, especially beef soup, be- 
longs to the foods which are prohibited in 
many reduction prescriptions.^ Without 
any theoretical justification, I, on the con- 
trary, recommend to each of my patients 
who feels no absolute repugnance to soup 
to begin his chief meal with this dish, and 
I believe I bring about an acceleration of 
satiety by the stimulation of the gastric 
secretion. 

Clear beef soup without fat has no 
nutritive value of consequence, even if a 
few green vegetables ("Julienne soup," 
cabbage soup) are added. In my eyes, 
it would be an injustice to forbid this dish, 
which is relished by the great majority of 

* Not by Ebstein and Von Noorden ! 
163 



DIETETIC TREATMENT OF OBESTIY 

men and which is necessary to many for 
the formation of a regular noon meal. 

In cases of " ravenous hunger " during 
the morning, which could not be removed 
by education, I gladly allowed the con- 
sumption of 150 or 200 Gm. of bouillon. 
It is to be had in many households in the 
late afternoon hours, or is saved from the 
previous day without losing in palata- 
bility and wholesomeness. The feeling of 
hunger is quickly appeased by a cup of 
soup. 

Finally, this result can be attained by a 
very small quantity of chocolate, by fruit, 
etc. But I found clear beef soup to be the 
most agreeable to the patient and the most 
effective calming agent for the torturing 
hunger. 



164 



CHAPTER XVII 

Every diet prescription should be made 
in writing, and every alteration should be 
written down in black and white, since 
otherwise incredible misunderstandings 
come to light. 

Since I consider it suitable to train the 
stomach to be content with a quantity of 
food less than that to which it has been 
accustomed, I allow no food to be eaten 
ad libitum, not even such as must seem 
harmless, considered from the standpoint 
of the theory of nutrition. Otherwise it 
would happen too easily that on the days 
on which less harmless dishes come to the 
table transgressions would occur, because 
the feeling of satiety would be absent. 
This might disturb or do away with the 
success. 

If the patient wishes it, and if the re- 
sult of the previous week does not speak 
against it, I increase the quantity of this 
or that course a certain amount, but do 
not yield to every whim of the patient. In 
this respect it is easy to begin, but diffi- 
cult to stop. 

165 



DIETETIC TREATMENT 

In the prescription all foods are meas- 
ured out according to weight. Only tea, 
which is to be put on a par with water, 
forms an exception. However, I deter- 
mine the milk which may possibly be 
added, as well as the weight of the sugar 
used to sweeten the tea. 

If the amount of the tea (and coffee) 
consumed in a day is slight, so that 20 
Gm. of sugar are enough to sweeten it, 
it is sweetened with sugar; but if the tea 
is drunk much sweeter, the patient must 
use in place of the sugar, at least in part, 
saccharin or crystallose or saxin. 

It is very important to measure out 
bread with the scales. A roll now weighs 
40 Gm. in Vienna. A short time ago it 
still weighed 50 Gm. Even in Vienna, 
bakers' wares are found to vary in weight 
according to the part of the city from 
which they come. The four-heller roll in 
small cities, and especially in the country, 
is so considerably heavier that this fact 
cannot be overlooked. Prescription ac- 
cording to weight makes us independent 
of such differences. 

All foods are weighed immediately he- 
fore the meal, as prepared for the table, 

166 



OF OBESITY 

Since, as was demonstrated in the earlier 
chapters, I measure out the amount of 
food, not at all or not exclusively accord- 
ing to the nutritive value, but regulate it 
according to the result, I can also dispense 
with having the foods prepared from the 
weighed amounts of previously analyzed 
raw materials, or with examining the foods 
ready for the table, calorimetrically. This 
would also be hardly possible in carrying 
out the treatment in the home of the 
patient. 

What is actually eaten is weighed. 
Bones or other inedible parts of the roast 
are removed before weighing, fruit peeled 
before weighing, the pits of stone-fruit 
weighed again and replaced by the meat 
of the fruit. 

The only exception is made in the case 
of poultry roasts. Stripping the meat 
from the bones would be troublesome 
and unappetizing. Poultry is therefore 
weighed with the bones, and a special 
figure referring to this is inserted in the 
prescription. In the case of small chick- 
ens, pigeons, partridges, the weight in pro- 
portion to other roasts is increased 40 per 

167 



DIETETIC TREATMENT 

cent.; in capons, ducks, geese, 20 to 30 
per cent. 

I attach value to the fact that the weigh- 
ing he undertaken at the table by the 
patient himself or some member of his 
family. The staff of the kitchen often 
combine a generous heart and shght con- 
scientiousness, and increase the portions 
without authorization, whereby naturally 
a gross source of error is introduced, which 
can ruin the success of the treatment. 

Although it is well known to me that 
the different kinds of vegetables and the 
various farinaceous foods differ in their 
nutritive value, and accordingly should 
not be given in equal amounts by weight, 
I prefer to do this in order not to make the 
prescription entirely too complicated and 
to give the patient daily equally large 
quantities, when possible, equal volumes, 
hence to cause him to feel the same degree 
of satiation. The weekly result depends 
upon the average value of the food given 
daily. Whether one day or another con- 
tributes more or less to this value is of no 
consequence. 

The patients ought not to determine 
their body weight oftener than once a 

168 



OF OBESITY 

week, for the reason just mentioned, and 
also because the water content of the 
organism can vary from one day to an- 
other by a more significant amount than 
the daily decrease in weight caused by 
loss of fat. In the case of my patients the 
variations of the water content can be 
very large, because I leave the consump- 
tion of water to the discretion of the 
patient. On days when spiced or strongly- 
salted foods are eaten, more water is 
drunk than on other days. The excess of 
water consumed can easily raise the body 
weight 500 Gm. higher than the day be- 
fore. Now, if the patient has lost 150 
Gm. of fatty tissue, his weight may appear 
350 Gm. higher. The ascertaining of this 
fact, the significance of which the patient 
does not recognize or which is not present 
to his mind, irritates him unnecessarily. 
This harm is not entirely compensated 
even when the weighing on the second day 
following shows a decrease in weight of 
650 Gm., which is composed of 150 Gm. 
of loss of fatty tissue and 500 Gm. of 
loss of water. 

These disturbing influences make them- 
selves much less conspicuous in weekly 

169 



DIETETIC TREATMENT 

weighings. The losses of fat in a week 
are seven times as great as those ascer- 
tained daily, but the weekly variations in 
the water content are not greater than the 
daily ones. 

This influence is not entirely eliminated. 
It happens, in spite of obedient conduct, 
that single weeks bring less loss of weight 
than was expected. The following week 
then brings compensation, but the average 
value of both weeks must be taken into 
account to judge the eiFectiveness of the 
treatment. These irregularities in the 
weekly result can be met to a certain ex- 
tent if the patient is enjoined always to 
eat, on the day of weighing and on the 
day before, meals of the same composition. 

Still another cause disturbs the uni- 
formity of the weekly losses in weight: 
menstruation. During the days before the 
appearance of the menses the weight of 
most women, even when they follow the 
treatment conscientiously, is increased 
somewhat. This increase, which is prob- 
ably due to the retention of water in the 
organism, and M^hich even the women 
notice (they feel stronger, have more 
difficulty in lacing their corsets, their 

170 



OF OBESITY 

breasts swell), can amount to more than 
one kilogramme. It can completely con- 
ceal the simultaneous decrease in weight 
due to loss of fat, when the day of weigh- 
ing falls upon the day of the appearance 
of the period or the first or second day 
before. The following weighing, then, 
generally shows an unusually large de- 
crease in weight, since the water content 
of the organism within a few days reverts 
to its old measure, and the decrease in 
weight which follows at an interval of 
two weeks finds its full expression. 

It would be demanding the impossible 
if our patients were required to follow the 
prescriptions for weeks and months at a 
time with absolute precision, and to avoid 
all " sins of treatment." 

I have formulated my demands with 
respect to this on the basis of abundant 
experience as follows: 

(1) In the first two weeks the treat- 
ment is to be carried out exactty, so that 
I can gain a correct picture of its efficiency 
and can judge whether or not changes in 
the prescription are necessary. 

(2) When in the later course of the 
treatment two or more weeks produce an 

171 



DIETETIC TREATMENT 

insufficient result, a " sinless " week is to 
be inserted, which enables me to decide 
whether the deviations from the prescrip- 
tion are responsible for the failure, or 
whether (on account of the decrease in 
weight, which has already appeared, and 
the consequent slighter food requirement) 
the form of diet is no longer suitable and 
must be replaced by another which is some- 
what more restricted. 

(3) All " sins " must be conscientiously 
confessed, since otherwise the physician 
loses every insight into the connection 
between change of weight and diet. 

(4) Greater but less frequent excesses 
are less harmful than small but often re- 
peated transgressions. Patients who eat 
several mouthfuls more than are allowed 
at every meal as a rule show no decrease in 
weight. 

(5) Whenever possible, the treatment 
should be strictly followed on the day be- 
fore weighing and on the day of weighing 
itself, since otherwise the increased con- 
tents of stomach and intestine can produce 
a considerable decrease in weight. 

(6) The patients are to be taught that 
three or more days of relapse into the old 

172 



OF OBESITY 

accustomed mode of life will cause the 
days conforming to the schedule of the 
treatment, which follow, to be again at- 
tended by hunger. They have made the 
treatment difficult for themselves, because 
the stomach must be trained anew to de- 
creased filling or even to omission of 
single meals. Therefore in the extremely 
large majority of cases it is to be recom- 
mended that the treatment be completed 
in one pull, 

(7) No cure without scales. Ocular 
measurement is unreliable, nor is it as in- 
corruptible as the scales.^ 

* Only twice in my practice have I seen successful 
treatments carried out without the use of the scales. 
In the first of the two cases an unusually energetic 
woman, who, by virtue of her position as lady at court, 
could not use the scales at the majority of her meals, 
succeeded in carrying out a cure in normal time with a 
decrease of 15 Kg. She ate of the abundant fare 
M^hich was offered her exactly as much as the prescrip- 
tion allowed. She had the quantities of the different 
foods permitted weighed off before the meal, and im- 
pressed them so well upon her memory that she hit 
the mark. The circumstances were similar in the 
second case, 



173 



CHAPTER XVIII 

Even infants may become too fat from 
overfeeding, and may suffer many dis- 
turbances of health from this abnormahty. 
Then the number of the daily meals and 
the duration of every single breast meal 
or the quantity of the artificial food is 
reduced, and thereby an improvement is 
gained, — that is, an increase in weight 
corresponding to the growth in height. 
Hence, even here we might speak of an 
obesity treatment. If in the meantime 
the conception of the word is limited so 
that an actual reduction of the existing 
weight is understood by it, the lower 
boundary at which such treatments are to 
be undertaken is to be placed at about the 
twelfth or thirteenth year in the case of 
girls, somewhat higher in the case of boys. 
In the case of still younger children it is 
enough to maintain the body weight at a 
constant height by suitable dietetic pre- 
scriptions, or at least to convert the rapid 
rise into a slower one, in order to reach 

174 



DIETETIC TREATMENT OF OBESITY 

the goal, — that is, to bring the body 
weight into a proportion to the height 
which corresponds somewhat to the nor- 
mal: provided that the children grow. If 
obesity and the repression of growth ap- 
pear in union, as in myxoedema, then, as a 
matter of course, etiological treatment — 
in myxoedema, the administration of thy- 
roid extracts will be ordered. ( This only 
incidentally. ) 

Some typical mistakes in nutrition give 
rise to the appearance of obesity in other- 
wise entirely healthy children. 

Many parents are not able to go far 
enough in the choice of foods which have, 
or are said to have, the very greatest 
nutritive value. What portion of meat is 
the most nutritious, and what mode of 
preparation increases the nutritive value 
still more, form the subjects of their 
studies. That they can also go too far in 
this, that an excess of food also works 
harm, they do not notice until their round 
darling is the object of the ridicule of his 
fellow-pupils or playmates. 

The two most frequent causes of over- 
nourishment of children are: 

(1) An excess of meat. 

175 



DIETETIC TREATMENT 

(2) An excess of bread, with or with- 
out butter. 

Compared to that, all other constituents 
of the daily food, sweets included, retire 
into the background, although, of course, 
the effect is determined by the total of all 
the articles of diet. As we have already 
seen, a child can devour bread in kilo- 
grammes, while it indeed seldom received 
more than 50 Gm. of chocolate or other 
sweets in a day. But in nutritive value 
this amount is about equal to 100 Gm. of 
bread. 

On the day on which I write this down, 
13-year-old twins (girls) were brought to 
me, who weighed respectively 73 and 72 
Kg, The children got meat to eat five 
times a day. This is a gross case of meat- 
fattening. To give meat three or four 
times daily instead of once or at most 
twice seems especiall}^ suitable to many 
parents. Let it be emphasized here, by way 
of parenthesis, that ham belongs to the 
meat species. Many laymen do not seem 
to know that, but regard ham as an article 
of diet sui generis which cannot be given 
to children often enough. 

With the aid of the body and food 

176 



OF OBESITY 

scales we succeed, as a rule, and without 
difficulty, in keeping younger children for 
some time at the same weight, or at least 
in checking the further rapid increase in 
their weight. 

Reduction of the amount of meat to the 
permissible degree and restriction of the 
consumption of bread are the most im- 
portant measures which enter into con- 
sideration in this connection. As a matter 
of course, such children will be made to 
take physical exercise. 

I have brought about actual reductions 
in weight in the case of girls from 12 to 
13 years of age and of boys from 15 to 
16 years of age. 

In the case of girls it is also a ques- 
tion of promoting the development of a 
normal shape of the breasts. The skin 
over the breast glands is at times, not 
always, a favorite place for the deposition 
of fat in the case of both sexes. Even 
in young men fat is often located there, 
so that at times a formation very similar 
to the female breast appears. 

But in the case of girls the simultaneous 
development of the glandular substance 
and the deposition of fat in the sub- 

12 177 



DIETETIC TREATMENT 

cutaneous cellular tissue may develop 
over-large breasts. The skin which covers 
them is distended and finally shows the 
reddish streaks which are observed at 
other times in the distention of the ab- 
dominal skin by pregnancy or large 
tumors. 

So long as the cushion of fat is retained, 
the appearance of the breasts is not so 
bad. But when the fat disappears as a 
result of sickness or obesity treatments, 
the skin becomes too wide ; ugly pendulous 
breasts are developed. 

I consider it a grateful and not impossi- 
ble task of the surgeon to remove the 
superfluous skin and to restore a more 
pleasing form to the breasts. But so long 
as this part of cosmetic surgery is not per- 
fected, care will have to be taken that 
enormous masses of fat be not deposited in 
the cellular tissue over the breast gland; 
that an obesity treatment be taken in 
hand in due time in young girls who have 
this easily recognizable morbid disposition, 
and that a later recurrent addition of fat 
be hindered by constant surveillance. 

I brought about very successful cures 
in more than 30 cases in girls at the ages 

178 



OF OBESITY 

of 13 to 16 years, and I prevented the 
appearance of the beauty blemishes de- 
scribed. Without exception, the cases 
were young creatures who did not suffer 
from chlorosis and who had a radiant ap- 
pearance. Menstruation was of different 
types. There was generally some dis- 
turbance present; the absence of menses 
for months or even years was often ob- 
served. Several of the patients were re- 
ferred to me by gynaecologists, who be- 
lieved that the reduction of flesh would 
serve as a means of awakening menstrua- 
tion or bringing it back. 

It is, indeed, generally known that 
obesity is usually combined with disturb- 
ances of the generative glands and of 
menstruation, most frequently with 
amenorrhoea. In the majority of cases a 
correctly conducted obesity treatment 
regulates this function, as will be shown 
more fully in a later chapter. Let it only 
be pointed out here that absence of the 
menses without chlorosis (normal hemo- 
globin content) ought to incite us to 
undertake an obesity treatment, not pre- 
vent us from doing it. 

Since in an obesity treatment we cannot 

179 



DIETETIC TREATMENT 

dispense with the cooperation of the 
patient, it will be necessary in determin- 
ing the duration of the treatment also to 
take into consideration his physical nature 
and development. 

A certain degree of maturity, whose 
expression consists in the fact that eating 
no longer represents the end and object 
of life, a little strength of will, and a 
little vanity, must all be present. In the 
case of corpulent children, who are not 
affected by the chaffing of their comrades, 
we must wait until they become older, 
until they themselves express the wish to 
appear like their companions of the same 
age. But even in the case of young peo- 
ple there is no danger in a slow and cau- 
tiously conducted treatment. 

No. XL, 48, a 13^ -year-old girl, came under 
my treatment at the end of 1911. Her father is 
corpulent. She herself came to the world weigh- 
ing 4 Kg., and has been too fat her whole life. 
Typhoid three years ago. Her weight began 
to mount rapidly during convalescence. 

She is always hungry, bowels regular with 

cathartics. For three months menses every 23 

days. Patient is characterized by the mother 

as lazy, although she takes gymnastic exercises 

180 



OF OBESITY 

and takes a daily walk of an hour. Sleeps nine 
hours. 

Diet before treatment: Seven o'clock: Cof- 
fee or tea, two lumps of sugar, one roll. 

Ten o'clock: Graham bread, 50 Gm;. of 
sausage, one apple. 

One-thirty o'clock: Soup, meat, vegetables, 
graham bread, fruit. Farinaceous foods at 
times instead of soup. 

Five o'clock : Coffee and a " Zuckerkipferl." 

Eight o'clock: Roast with side dishes (often 
preserves) or cold meat, graham bread. Every 
day a loaf of graham bread costing 20 hellers 
is eaten. Her family believes that this sort of 
bread does not fatten. 

The girl has fat breasts ; the gland tissue is 
very little developed. A regular " hump of 
fat " has a very disfiguring effect. On account 
of large masses of fat the neck seems to be 
m,uch too short in the back. The arms are 
enormously fat. 

Height at the beginning of the treatment, 
161 cm., weight (with clothes), 72.90 Kg. 

It is decided to reduce the weight by about 
10 Kg. and to regard every centimetre of 
growth in height during the treatment equal to 
a decrease in weight of 1 Kg. 

After some corrections the following diet 
proved to be the suitable one with which to at- 
tain a decrease in weight, proceeding at the 
proper rate and with the least hunger. 
181 



DIETETIC TREATMENT 

In the morning: Tea, two teaspoonsful of 
milk, two lumps of sugar, 40 Gm. of rolls, 15 
Gm. of Emmentaler cheese, 150 Gm. of apples. 

Noon: 150 Gm. of beef soup with little solid 
constituents, 90 Gm.. of lean roast or beef or 
130 Gm. of chicken, 140 Gm. of green vege- 
tables, 50 Gm. of farinaceous foods, 100 Gm. 
of apples, no bread, water ad libitum. 

Five o'clock : Tea, two teaspoonsful of milk, 
two lumps of sugar, 20 Gm. of rolls. 

Evening: 100 Gm. of roast or 140 Gm. of 
chicken, 100 Gm. of lettuce or cucumbers, 200 
Gm. of apples or pears or oranges, no bread ; 
or: 80 Gm. of cold meat and 40 Gm. of bread 
and butter, 200 Gm. of fruit. 

Course of weight curve (in abstract) : 

November 19, 1911 72.90 Kg. 

November 27, 1911 71.45 Kg. 

December 18, 1911 70.00 Kg. 

January 16, 1912 68.40 Kg. 

February 13, 1912 66.70 Kg. 

March 19, 1912 65.80 Kg. 

The treatment is concluded and the 
patient dismissed with a normal diet. She 
presents herself repeatedly, the last time 
on May 21, and she weighed then 65.25 
Kg. Her height is now 165 cm. There- 
fore since the beginning of the treatment 
she has grown 4 cm. in height, 

182 



OF OBESITY 

Except for the first three days of the 
treatment, she never complained of hun- 
ger, was well satisfied with her meals, and 
appears in radiant health. 

The menses appeared on November 20, 
December 14, January 17, February 20, 
March 16, April 19. 

The bowels had become somewhat more 
sluggish. On that account a wineglassful 
of Apenta water was given her once or 
twice a week. 

Her figure now corresponds to that of 
a girl who is healthy, large, but with a 
perfectly normal figure. The hump of 
fat has completely vanished, the neck has 
become much longer, and the arms are 
several centimetres thinner. The change 
of appearance in toto is so significant that 
the decrease (7.65 Kg. with an increase 
in height of 4 cm.) would be considered 
much greater than it actually is. 

The observance of the normal diet is 
not difficult for the girl, so that I con- 
sider a permanent success certain. 

I v/as able to record a well-established 
permanent success in the case of a girl 19 
years old. I intend to state this case only 
briefly, because the indication for under- 

183 



DIETETIC TREATMENT 

taking the treatment was not beyond 
doubt. That is to say, there were huge 
but well-rounded breasts, and it seemed 
certain that the treatment would reduce 
these materially in extent and weight and 
also in turgescence. The girl was 170 
cm. tall and weighed 104 Kg. The con- 
sciousness that she was ill-shaped had 
such a depressing effect upon her spirits 
that she evaded every contact with men, 
and especially could not be induced to 
take part in social pleasures, which were 
open to her in great abundance. 

She lost 22 Kg. in a treatment lasting 
20 weeks which was very easy for her. 
Her form was now that of a buxom, but 
by no means abnormal, girl. 

The feeling that she no longer struck 
people as a prodigy was her salvation. 
Even before the conclusion of the treat- 
ment she began to attend balls, soon be- 
came engaged, and has now been for many 
years a happy wife and mother of several 
children. I have not seen her for a long 
time, but know that she has remained 
slender. 

The upper age limit at which patients 
are fit for obesity treatment cannot be 

184 



OF OBESITY 

drawn. One of the most experienced 
Vienna physicians has repeatedly sent me 
patients who had passed their sixtieth 
year, and who then regained so much in 
working efficiency and activity by a 
treatment, carried out without any delay, 
that they themselves characterized it as a 
rejuvenating cure. More than 20 Kg. 
was removed in one of these cases. 

A 65-year-old patient, whose active 
spirit suffered a forced physical inactivity 
because of her great weight — she could 
only cover short stretches of level ground 
— reported to me, after completing the 
treatment, that she could now master very 
steep mountain paths again (saddle be- 
tween Altausee and Grundlsee) with the 
greatest ease. 

Twice I have successfully treated 70- 
year-old patients, a gentleman and a lady, 
who suffered under the combined effect of 
obesity of high degree and a (compen- 
sated) heart lesion. In both cases the 
patients, who were hardly able to get to 
my office in rolling chairs, were put on 
their feet again. 

But the age record of my patients is 
held by a woman who was no less than 

185 



DIETETIC TREATMENT 

80 years old when she called upon me to 
submit to a reduction treatment. The 
chief motive which led her to seek me was 
■ — female vanity. She said she could no 
longer look at herself in the mirror since 
her weight, which had previously 
amounted to no more than 80 Kg., had 
risen to 97 Kg. Diminished activity 
occupied only a second place as a motive 
for her resolution. After I had convinced 
myself that no psychosis was at hand, I 
attempted, first in jest, then in earnest, 
to dissuade the lady from her purpose, 
but encountered the most energetic opposi- 
tion. My refusal to assist her made her 
angry, and she solemnly declared that she 
would carry out the reduction by a very 
radical hunger treatment or by means of 
a borrowed diet prescription. By refus- 
ing to give her advice I would have made 
myself responsible for the termination of 
the affair. 

I repeatedly found myself in similar 
situations when women (the same thing 
does not occur in the case of men), who 
are certainly not excessively heavj^ wish 
to reduce. As a matter of course, such 
wishes must not be complied with. I 

186 



OF OBESITY 

failed in only one case to dissuade the lady 
from her foolish purpose by persuasion, 
and by exhibition of the table which con- 
tains the correct relation between body 
weight and height. A woman well along 
in the forties, who was 15 Kg. too light, 
whose arms, legs, and upper body con- 
sisted chiefly " of skin and bones," could 
not be convinced. She came again and 
again. She said that on the lowest part of 
her back fat had collected which abso- 
lutely had to " go." Now in this case I 
considered it necessary, in the interest of 
the mental composure of the patient, to 
follow out a dietetic prescription. I did 
not see the patient again from that time 
on, therefore I do not know whether she 
has followed my prescription. In my 
opinion, she might have attained a steady 
increase in weight with it. I gave her a 
good piece of advice against her will. 

But the case of the 80-year-old lady was 
different. She was actually too heavy. 
Aside from her age, there was no contra- 
indication, and so I decided to make a very 
cautious attempt. I gradually restricted 
the diet, " feeling mj^ way " (with the 

187 



DIETETIC TREATMENT OF OBESITY 

scales), until a decrease in weight made 
its appearance. 

The total loss amounted to 7 Kg. in 9 
months. She never complained of hun- 
ger and was in perfect health. 

Many of my patients considered the 
treatment a happy event in their lives ; the 
octogenarian was one of the happiest of 
all. 

I would therefore answer the question: 
At what time of life are obesity treatments 
permissible? In the case of girls, 12 to 
13 years; in the case of boys, 15 to 16 
years. The upper limit cannot be deter- 
mined. 



188 



CHAPTER XIX 

It is a fact generally known that a con- 
siderable part of the obese people die of 
apoplexy. In families in which obesity 
is of frequent occurrence (there is an 
hereditary form of this affection) sudden 
death can be recorded much more fre- 
quently than among the rest of humanity. 
I have often heard in the histories of peo- 
ple in whom obesity was hereditary: 
" My father, from whom I inherited the 
trouble, grandfather, father's brothers, all 
died of apoplexy." 

Whether the number of apoplectic 
strokes, is less among those who do not 
inherit obesity than among those who do, 
I do not know, but I suppose, on the basis 
of blood-pressure measurements, that no 
substantial difference exists in this re- 
spect. 

Obesity also belonged to the " apoplec- 
tic habit " of the old physicians. 

Not merely hemorrhage of the brain, 
but also sudden heart-failure, as is well 
known, frequently occurs among stout 
people. 

The tendency to these kinds of death 

189 



DIETETIC TREATMENT 

can be diagnosed, if not without excep- 
tion, yet very frequently, by taking the 
blood-pressure. 

As the inventor of the tonometer, one 
of the two instruments for the measure- 
ment of blood-pressure, I have since the 
birth-j^ear of this instrument industriously 
practised this method of investigation, the 
indispensability of which is to-day gener- 
ally recognized. The blood-pressure is 
determined in every one of my patients. 
If the first investigation shows abnormal 
conditions, the measurement is repeated 
at every recording visit, but otherwise only 
at greater intervals. 

Xow, it has been shown that high 
blood-pressure values occur very frC" 
quently in the case of obese people, cer- 
tainly incomparably more frequently 
than among men of the same age with 
a normal amount of fat. 

The following table, which includes 100 
consecutive cases from my practice, clearly 
teaches that absolutely normal values 
occur only in 54 per cent, of the cases. 
Moderately increased blood-pressure 
(115-140 mm. Hg) in 27 per cent., and 
high blood-pressure, 140 mm. Hg. or over, 
in 19 per cent, of the cases. 

190 



OF OBESITY 

I am able to give no definite informa- 
tion as to the causal connection between 
obesity and high blood-pressure. But that 
this connection actually exists is taught 
not merely by the frequent coincidence of 
both disturbances, but with much greater 
certainty by the fact that the blood- 
pressure can he reduced without eoocep- 
tion by an obesity treatment. Not seldom 
in the course of the treatment the blood- 
pressure sinks to the normal. 



Number. 


Sex. 


Age. 


Weight, 
Kg. 


Height, 
cm. 


Blood-pres- 
sure, mm. Hg. 


1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 


F. 
M. 
M. 
F. 
F. 
F. 

f: 

F. 

F. 

F. 

M. 

F. 

F. 

M. 

F. 

F. 

M. 

M 

F. 

F. 

M. 


32 
43 
26 
31 
23 
48 
57 
45 
36 
32 
42 
49 
39 
34 
48 
60 
16 
32 
67 
37 
34 
34 


114 
90 

100 
82 

116 

121 
89 

117 
85 
89 

103 

103 
83 
64 

105 
99 
77 
75 
90 
82 
97 
92 


161 
172 
169 
164 
156 
175 
174 
171 
166 
160 
160 
170 
160 
155 
177 
160 
167 
153 
168 
157 
171 
176 


165-115 
108 
140 

115- 90 
105 
115 
118 
125 
100 
120 
110 

200-155 
85 
110 
100 
170 

165-130 
110 

165-120 
105- 95 
110 
120 



191 



DIETETIC TREATMENT 



Number. 


Sex. 


Age. 


Weight, 
Kg. 


Height, 
cm. 


Blood-pres- 
sure, mm. Hg 


23 


F. 


38 


73 


157 


100 


24 


M. 


34 


105 


174 


100- 90 


25 


F. 


19 


101 


174 


105 


26 


M. 


35 


90 


176 


115 


27 


F. 


30 


84 


163 


115 


28 


F. 


46 


102 


170 


105 


29 


F. 


32 


71 


165 


100 


30 


F. 


44 


84 


166 


100 


31 


F. 


51 


91 


153 


120-100 


32 


M. 


53 


133 


181 


120 


33 


F. 


40 


73 


153 


95 


34 


M. 


32 


85 


171 


117 


35 


M. 


36 


106 


180 


115 


36 


M. 


40 


88 


177 


110- 95 


37 


F. 


38 


100 


166 


85 


38 


F. 


47 


96 


166 


120 


39 


F. 


32 


75 


161 


90 


40 


M. 


50 


106 


176 


90 


41 


M. 


31 


102 


169 


120-100 


42 


F. 


33 


117 


162 


130-100 


43 


F. 


52 


79 


163 


140-100 


44 


M. 


46 


90 


169 


110 


45 


F. 


42 


89 


165 


100 


46 


F. 


52 


69 


160 


110 


47 


F. 


24 


86 


171 


120 


48 


F. 


28 


90 


164 


110- 90 


49 


F. 


46 


78 


163 


100 


50 


F. 


31 


69 


159 


110 


51 


F. 


44 


89 


158 


110 


52 


F. 


26 


106 


176 


116-100 


53 


F. 


48 


78 


159 


90 


54 


M. 


44 


96 


176 


150-108 


55 


F. 


28 


76 


165 


90 


56 


M. 


66 


97 


173 


200 


57 


F. 


40 


84 


166 


130-100 


58 


F. 


32 


74 


158 


110 


59 


F. 


30 


96 


162 


100 


60 


M. 


29 


86 


173 


92 


61 


F. 


45 


76 


155 


95 


62 


F. 


30 


101 


178 


90 


63 


F. 


17 


84 


167 


140 



192 



OF OBESITY 



Number. 



Sex. 


Age. 


F. 


20 


M. 


39 


F. 


40 


F. 


41 


F. 


45 


M. 


31 


M. 


53 


M. 


47 


F. 


42 


M. 


36 


F. 


37 


M. 


35 


F. 


20 


F. 


45 


F. 


55 


F. 


52 


M. 


66 


M. 


44 


F. 


27 


F. 


30 


F. 


49 


F. 


38 


F. 


22 


F. 


38 


M. 


35 


F. 


28 


F. 


42 


F. 


53 


M. 


39 


F. 


26 


F. 


23 


F. 


30 


M. 


48 


F. 


52 


F. 


34 


F. 


37 


F. 


40 



Weight, 
Kg. 



Height, 
cm. 



Blood-pres- 
sure, mm. Hg. 



64 
65 
66 
67 
68 
69 
70 
71 
72 
73 
74 
75 
76 
77 
78 
79 
80 
81 
82 
83 
84 
85 
86 
87 
88 
89 
90 
91 
92 
93 
94 
95 
96 
97 
98 
99 
300 



82 
83 
94 
94 
95 

111 
87 
93 

103 
88 
81 
84 
76 
92 
74 
80 

114 
81 
80 
95 

129 

100 

115 
72 
95 
90 
93 
98 

105 

96 

92 

P 84 

89 

135 
92 
99 

107 



162 
171 
170 
175 
155 
181 
175 
175 
155 
170 
160 
174 
158 
160 
157 
161 
170 
174 
159 
153 
151 
165 
170 
159 
174 
171 
167 
159 
181 
165 
157 
162 
174 
164 
165 
159 
173 



95 
110 
110 
116 
105 
115 

140-118 
105 
145-100 

90 
100 
100 

95 
100 

140- 95 
135-115 
145-118 
150-120 
110 
100 
175 
100 

130-115 
180-110 
100 
120 

140-128 
150 

115-100 
130 

110- 95 
115 
110 
120 
115 
110 
100 



The second figure in the column " blood-pres- 
sure " gives the pressure in the course or at the 
13 193 



DIETETIC TREATMENT 

end of the treatment. Its absence signifies that 
repeated measurements were impossible. 

Even among the 100 cases contained in 
the table, 20 can be found in which the 
treatment brought about a substantial 
diminution in the blood-pressure. 

No. 1 shows a fall of 165 to 115. 

No. 12 shows a fall of 200 to 155. 

No. IT shows a fall of 165 to 130. 

No. 19 shows a fall of 165 to 120. 

No. 31 shows a fall of 120 to 100. 

No. 36 shows a fall of 110 to 95. 

No. 41 shows a fall of 120 to 100. 

No. 42 shows a fall of 130 to 100. 

No. 43 shows a fall of 140 to 100. 

No. 54 shows a fall of 150 to 108. 

No. 57 shows a fall of 130 to 100. 

No. 70 shows a fall of 140 to 118. 

No. 72 shows a fall of 145 to 100. 

No. 78 shows a fall of 140 to 95. 

No. 79 shows a fall of 135 to 115. 

No. 80 shows a fall of 145 to 118. 

No. 81 shows a fall of 150 to 120. 

No. 86 shows a fall of 130 to 115. 

No. 87 shows a fall of 180 to 110. 

No. 90 shows a fall of 140 to 128. 

In judging these statistics, it is to be 
well noted that in many of the patients 

194 



OF OBESITY 

who came under my treatment with high 
pressure values, no decrease in these were 
observed, because the patients did not ap- 
pear again, whether because I lost sight 
of them entirely, or whether because they 
sent me later only written reports and 
blood-pressure measurements were not 
taken by the family physicians. 

In the cases which I could personally 
record, the diminution of the blood- 
pressure appeared without exception, and 
could be noticed after the expiration of 
the first week of the treatment — at the 
latest, in the course of the second week 
of the treatment. The fall in pressure 
was rapid at first, and then became gradu- 
ally less sharp. As already mentioned, it 
was never absent, not even in cases in 
which a complication of obesity with 
hardening of the arteries, or with con- 
tracted kidneys, was present. 

It seems to me that no slight signifi- 
cance is to be attached to this observation, 
since no other way is known, either in lit- 
erature or in our own experience, by which 
to lower the blood-pressure so vigorously 
with certainty and for a long time. 

My experience taught me that blood- 

195 



DIETETIC TREATMENT 

pressure remains low so long as the 
patients observe the diet of the treatment 
and the subsequent normal diet. But it 
rises again as soon as they eat more than 
is necessary to maintain a uniform weight. 

A faithful patient who, contrary to my 
intentions, has been taking an obesity 
treatment every year for six years, be- 
cause he cannot bring himself to follow ^ 
the prescribed diet after the conclusion 
of the real period of treatment, constitutes 
a voluntary object of experiment for the 
relations discussed here, and one which 
cannot be rated high enough. 

Every spring he makes his appearance 
because his weight has risen to about 100 
Kg. in the meantime, and he begins the 
treatment every year with a blood- 
pressure of about 150 mm. Hg. The pre- 
scription is followed with great conscien- 
tiousness, the weight falls from 10 to 14 
Kg., and the blood-pressure almost to the 
normal. 

Slight but nevertheless unmistakable 
indications of an incipient cardiac insuffi- 
ciency as a result of greater exertions 

^ He takes long trips which lead him to America 
every year. On the way, however, — that is, during an 
ocean voyage, — it is hard to remain moderate in diet. 
196 



OF OBESITY 

(dyspnoea and palpitation of the heart 
during the more rapid chmbing of moun- 
tains or steps) disappear along with the 
diminution of the blood-pressure, which, 
as usual, takes place very quickly in the 
beginning of the treatment and at a time 
when the decrease in weight has not yet 
proceeded far enough to give a sufficient 
explanation in itself of the improvement 
which the patient perceives in his activity. 
While patients with normal or slightly 
increased blood-pressure do not usually 
perceive the benefit of the unloading of 
weight until after several weeks of the 
treatment, it can be considered the rule 
that patients with high blood- pressure can 
report a regular revolution in their health 
even after a few days. 

They walk freely again, can also ascend 
mountains or climb stairs, and they sleep 
better. 

If we take into consideration the fact 
that the reduction of the blood-pressure 
from 200 mm. Hg to 150 signifies an un- 
loading of the heart by 25 per cent., we 
will find the improvement of the subjective 
health intelligible. But we could not com- 
prehend, without knowledge of the blood- 

197 



DIETETIC TREATMENT 

pressure, why a man who weighs 120 Kg. 
and can no longer cHmb stairs regains this 
abihty as soon as he has reduced his weight 
to 118 Kg. The diminution of the blood- 
pressure, perceptible in the first days of 
the treatment, furnishes the key to the 
comprehension of this accompanying phe- 
nomenon, which is a godsend for the 
patient. 

Many a patient had to rejoice more 
over the reduction of the blood-pressure 
than over the reduction of the body weight, 
since the former increases his working 
efficiency still more than the latter. 

I can propose only suppositions as to 
how the reduction of blood-pressure pro- 
ceeds, because nothing definite can be 
asserted as to the connection between 
obesity and hypertension. 

It might be supposed that the viscosity 
of the blood would be diminished by the 
treatment, and friction-obstacles between 
blood and vessel wall reduced.^ 

This would not be difficult to ascertain 
in the hospital or sanatorium. But 

- Georg Hirt, in his " Parerga zum Elektrolj'tkreis- 
lauf," Munchen, 1912, expresses a similar opinion. 

198 



I 



OF OBESITY 

hitherto I have found it impossible with 
my clientele, which consists of walking 
patients. 

Perhaps the unburdening of the gastric 
and intestinal canal in the case of men 
who pass from immoderate eating to very 
moderate consumption of food enters the 
question. This manifests itself even in 
the first days of the treatment, also in 
other ways, by diminished tension of the 
abdomen, disappearance of the bloating, 
etc. Dr. S. Federn, the indefatigable 
champion of clinical blood-pressure 
measurement, has again and again em- 
phasized the significance of the sympa- 
thetic nervous system with relation to the 
blood-pressure of men. This C. Ludwig 
and his pupils established in animal 
experiments. 

I have already mentioned that the great 
fall in weight of the first days is based in 
considerable part upon the dehydration 
of the organism. If now the blood takes 
part in this process, this would be equiva- 
lent to a diminution of the total blood 
mass, and this might then reduce the 
blood-pressure like a bloodletting, but 

199 



DIETETIC TREATMENT 

with the difference, to be sure, that in 
bloodletting, which only has a temporary 
effect, the blood mass is quickly regener- 
ated, while the dietetic treatment creates 
conditions which last as long as the treat- 
ment itself. 

Since the recognition of the great in- 
fluence of the suprarenal capsules and 
other glands with internal secretion upon 
the blood-pressure, the number of possi- 
bilities which have to be heeded in this case 
has become still greater. The possibility 
would not be excluded that the altered 
diet may also influence the function of 
these organs in the sense that a lowering 
of the blood-pressure results. 

The blood-pressure is often seen to sink 
steadily in the later stages of a " great " 
treatment. The following clinical his- 
tories furnish an example of this kind. 
I cannot rid myself of the impression that 
the disappearance of great masses of fat 
had a direct participation in the lowering 
of the blood-pressure. 

The blood-pressure must be so high that 
all organs receive as much blood as is 
necessary to maintain their individual life. 

200 



OF OBESITY 

A complete interruption of the circula- 
tion, as well as a continuously insufficient 
blood supply, involves death, necrosis of 
the aiFected organ or part of the organ, 
also that of the fatty tissue. 

The demands upon the blood supply 
made by the vital organs, for example the 
kidneys (here we should probably exclude 
fatty tissue), are much greater. The 
kidneys must obtain as much blood as is 
necessary to maintain their functional 
activity. If a part of the kidney tissue is 
destroyed, the remainder must accomplish 
all the work which the complete organ 
formerly accomplished. Compensation is 
brought about by extension of its own 
vascular system, and, if this does not 
suffice, by increase of the arterial blood- 
pressure. Organs not concerned can pro- 
tect themselves against the inundation by 
contraction of their own blood-vessels. I 
do not consider the possibility excluded 
that in case of great obesity blood-pressure 
is increased by an unknown regulatory 
influence, and that thus provision for suffi- 
cient supply of blood is created for the 
tissues extremely deficient in vessels. Dis- 

201 



DIETETIC TREATMENT 

appearance of fat would then exert the 
opposite influence — the decline in the 
height of the blood-pressure actually- 
observed. 

The correctness of this hypothesis might 
be studied in animals, who can easily be 
fattened. 

The following clinical histories, which 
I could supplement by numerous others, 
teach the connection between reduction of 
weight and the lowering of high blood- 
pressure : 

No. XXVI, 23, the 50-year-old trainer and 
racing driver, was born in America, but has lived 
for many years in Vienna. I have already men- 
tioned him. Father and mother each weighed 
over 200 pounds. He himself weighed 84 Kg. 
at the age of 20, and his weight increased from 
that time at the rate of about 1.5 Kg. a year. 
Five years ago, after a fall from his vehicle, 
attacks of vertigo, repeated occasionally. 
Cardiac dulness on the right side a little ex- 
tended (middle of sternum), cardiac sounds 
clear, second aortic sound accentuated. Patient 
does not smoke, and abstains from alcohol. 
Recently short of breath during quick walking 
or other physical exertions. No complaints 
about stomach. Bowels somewhat constipated. 
202 



OF OBESITY 

*' American cathartic pills," therefore, used. 
Sleeps 9 hours, quietly. Patient walks daily 
7 to 8 km. and drives 5 to 6 hours, often with 
young horses. Intense muscular exertion is in- 
volved in this occupation. The muscles of the 
hands and arms are those of an athlete. 
^ Diet up to this time: 

Seven o'clock in the morning: Coffee, one 
roll. 

One-thirty o'clock: Soup, roast, vegetables, 
farinaceous foods occasionally, one roll, water 
or tea. 

Two o'clock: Coffee with cream, milk bread. 

Seven o'clock: Cold meat, one roll, butter, 
pastry and preserves, lemonade with sugar. 

Height, 168.5 cm. 

The man is put on the following diet: 

Seven o'clock: 250 Gm. of weak coffee, two 
lumps of sugar, 50 Gm. of white bread. 

Twelve o'clock: 200 Gm. of bouillon, 150 
Gm. of beef or lean roast, 220 Gmi. of green 
vegetables, 200 Gm. of apples, water ad libitum. 

Two o'clock: 150 Gm. of weak coffee. 

Seven o'clock: 140 Gm. of lean, cold meat, 
150 Gm. of cucumbers, salad, or American pre- 
serves with little sugar, 40 Gm. of bread (drop- 
ped beginning January 19th), 20 Gm. of cheese 
and 150 Gm. of apples, water or unsweetened 
tea ad libittim,, 

203 



DIETETIC TREATMENT 





Gross 


Blood - 




Date 


weight. 


pressure 


Remarks. 




Kg. 


mm.Hg. 




December 8, 1906. . . 


111.30 


180 


Beginning of the treat- 
ment. 


December 15 


106.50 


155 


Only in the first days 
a little hunger, later 
absolutely perfect 
health; breathes 
much more easily. 


December 22 


105.40 


140 


Good health; more ac- 
tive. 


December 29 


103.85 


130 


Good health. 


January 12, 1907... 


101.80 




Good health. 


January 19 


101.10 


130 


Good health. 


January 26 


100.20 


. . . 


Good health. 


February 9 


98.20 


115 


Good health. 


March 23. 


96.50 


115 


On March 17th, arove 




the first race of the 








year with brilliant 








results. 



As can be seen from the table, the blood- 
pressure has decreased in the course of 
two months 65 mm. (from 180 to 115 
mm. Hg). 

No. XXXIII, 42, patient is 54 years old, 
cook. Her mother was obese and died of an 
apoplectic stroke. Three years since the meno- 
pause ; since then the weight has grown rapidly, 
7 Kg. in the course of last summer. Patient 
complains of pains In her legs. Legs refuse 
to work. In walking, even on level ground, 
dyspnoea and palpitation of the heart. Her 
occupation forces her to stand for hours at a 
time. This also is very difficult for her. Com- 
plete Inability to follow her occupation seems to 
be close at hand. 

204 



OF OBESITY 

She comes to me on November 10, 1908, upon 
the recommendation of her family physician. 

Former diet : Morning : Coffee without bread. 

Noon : Meat, vegetables, and a little farina- 
ceous food. 

Five 'clock : Coif ee without bread. 

Evening: No real mieal. Foods intended for 
her employers are only " tasted." As a drink, 
only water. 

Second aortic sound accentuated, otherwise 
no noteworthy findings. No albumin in urine. 

The weight of the patient, who is only 15^ 
cm. in height, amounts to 101.80 Kg. ; is, there- 
fore, 45 Kg. too high. 

The clinical history is instructive. By 
hearing or reading, the impression could 
easily be obtained that we have to deal 
with a person who takes very little food, 
and who has done everything possible not 
to become fat. Only one single, " regu- 
lar " meal, and even at this the dreaded 
farinaceous foods only "tasted"! The 
consumption of bread is altogether dis- 
claimed. The inexperienced man could 
easily arrive at the assumption in this case 
that he had a case of very sluggish tissue- 
change to deal with, which could not be 
affected by prescriptions usual in other 
cases. We are really not in a position to 

205 



DIETETIC TREATMENT 

restrict the diet more than this patient 
has done herself, or beheves she has done. 

Experience taught me that in measur- 
ing out food we have to be guided by very 
many circumstances. The statements of 
the patients, especially of women, as to 
their earlier scanty nutriment are, how- 
ever, not to be heeded, and directions are 
to be given as though we were quite sure 
that the patients had eaten too much 
hitherto. In the case under discussion the 
professional tasting of the foods might 
have given us the clue. In other cases it 
is false statements, often direct self-de- 
ceptions, which, for example, consist in 
the fact that single days of especially 
scanty diet are given as the normal ones.^ 

The case of " alleged " abstemiousness 
in the consumption of bread forms a rare 
exception. But the statements are usually 
most unreliable precisely in this point. 
The remembrance of eating bread is fre- 
quently buried in our subconscious mind, 
and must be brought out by a thorough 
inquisition. 

^ I met with the most extreme example of this kind 

in the case of a lady who stated that her only food in 

the last months had been three cups of unsweetened tea 

a day. She carried out a successful normal treatment. 

206 



OF OBESITY 

I prescribed the following diet: 

Morning, 6.30 o'clock: 200 Gm. of coffee 
with milk, one lump of sugar. 

Eleven o'clock: 150 Gm. of clear beef soup. 

Two-thirty o'clock : 90 Gm. of beef or roast, 
150 Gm. of green vegetables, 50 Gm. of farina- 
ceous foods, 150 Gmi. of apples, no bread. 

Five o'clock: 100 Gm. of coffee with milk, 
one lump of sugar. 

Eight o'clock: 100 Gm. of lean roast or 80 
Gm. of cold meat or sausage or dish composed 
of two eggs, 40 Gm. of rolls, 150 Gm. of apples 
or cucumbers ; as a drink, water ad libitum. 

The progress of the treatment can be 
seen from the following table, given in 
abstract : 



Date. 


Weight in 
clothes. 


Blood- 
pressure 


Remarks. 


November 10, 1908. 


101.80 


170 


Beginning of treatment. 


November 17 


99.30 


160 


Respiration freer. 


December 2 


96.70 




Euphoria. 


December 22 


94.30 


iso 


Pains in the legs are 
materially better. 
Sleep much better 
than before. 


January 20, 1909 . . . 


92.30 


120 


Patient became ill with 
influenza during the 
last few days; now 
well again. 


February 26 


85.50 


130 


Euphoria. Normal diet 
prescribed. 


December 1 


84.80 


130 


Complete euphoria and 
ability to follow oc- 
cupation. 



207 



DIETETIC TREATMENT 

I saw the patient again on November 
30, 1911. She had kept the same weight 
for a year. Since then slow increase. The 
pains in the legs become perceptible 
again; at times slight attacks of vertigo. 
The condition of her health in other re- 
spects, and the ability to follow her occu- 
pation, have remained good. She comes 
to me in order to meet in due time further 
increases in weight and the troubles con- 
nected with that. 

In a regimen which has been only un- 
essentially modified as compared to the 
one last prescribed, I record: 



Date. 


Weight, 
Kg. 


Blood- 
pressure, 
min.Hg. 


Remarks. 


November 30, 1911. 

December 7 

December 19 

January 9, 1912 

February 10 


90.70 

88.20 
86.45 
85.50 
84.20 


165 

150 
120 
100 
120 


Begimiing of the new 
treatment. 

No more vertigo. 

Euphoria. 

Health excellent. 

Complete euphoria. Is 
dismissed with nor- 
mal diet. 



It would not be difficult for me to print 
several dozens of such clinical histories. 
But I hope the particulars stated suffice 
to prove the correctness of two theses : 

208 



OF OBESITY 

(1) Obesity is frequently, at least in 
40 per cent, of the cases, accompanied by 
high blood-pressure. 

(2) The dietetic treatment of obesity 
lowers blood-pressure without exception. 
Since I know no other means which would 
be so effective in this direction, I consider 
the undertaking of such a treatment 
urgently indicated in the case of men with 
materially increased hlood-pressure (140 
mm. Hg, or over). In that case it often 
fulfils an indicatio-vitalis. 

Shortly before this book goes to press, 
I am in receipt of a work of Hecht, of the 
Wildbad Sanatorium,* which arrives at 
very similar conclusions. 

Hecht found in a large amount of ma- 
terial that increases in blood-pressure 
which must be traced to unsuitable mode 
of life, hence to excess nutriment, abuse 
of alcohol, tobacco, and other excesses, 
can be reduced by dietetic treatment, espe- 
cially if the increase in the blood-pressure 
is not of long standing. The means which 
led to the goal were : Non-irritating diet, 
diminution in the supply of meat, empha- 

*Zeitschr. f. klin. Medizin, 1912. 
14 209 



DIETETIC TREATMENT OF OBESITY 

sis on the vegetable form of diet, restric- 
tion of the use of alcohol, and mental rest. 
According to my observations, however, 
success in this depends alone upon the 
absolute restriction of diet, down to the 
normal diet or lower. 



210 



CHAPTER XX 

Among the first hundred of my patients 
there was a very distinguished actress, a 
member of our leading art institute. She 
underwent an obesity treatment of moder- 
ate extent, which reduced her weight 10 
Kg. in 10 weeks. In a letter the lady ex- 
pressed her joy at the success, which also 
involved an increase in her activity. 
Among other things, it said: " Since the 
beginning of the treatment I have no 
longer suffered from the fearful attacks 
of migraine, with which I have been 
afflicted at short intervals for many years." 

The subsequent completion of the 
clinical history showed that typical, severe 
attacks of migraine appeared several 
times a month without demonstrable 
cause, which stopped completely from the 
first day of treatment. Since that 
time, eight years have intervened, and the 
attacks have never returned with the same 
violence and have been extremely infre- 
quent. 

Until then I had bestowed little atten- 
tion upon migraine. The successful case 
just mentioned, an unforeseen supple- 

211 



DIETETIC TREATMENT 

mentary advantage of the treatment, 
caused me to search for migraine in every 
later case and also to give in the course 
of the treatment full attention to the 
attacks, according to their number and 
intensity. 

It appeared that in a large number of 
cases the migraine ceased completely, or 
at least decreased materially in every 
direction — frequency and severity of the 
attacks. 

It was without exception the typical 
migraine cases which reacted thus, while 
other kinds of headaches of neuralgic or 
rheumatic nature were not influenced at 
all, or scarcely any. 

However, a certain form of migraine 
generally behaved in a refractory manner : 
the attacks which are connected with men- 
struation and which occur during, shortly 
before, or shortly after menstruation 
(every case has its individual time), re- 
main uninfluenced.^ 

I have kept my patients and myself 
from disappointments by not holding out 
prospects of a favorable influence of the 

^ I have met :^dch cases not infrequently. For example, 
in a series of 58 patients (female), suffering from mi- 
graine, no Iq^s than 7 are found whose attacks without 
exceptioi; coincide with menstruation. 
212 



OF OBESITY 

treatment upon the attacks in cases of 
this kind. 

As is well known, migraine is essen- 
tially an hereditary disease. The tendency 
to attacks of migraine is transmitted. The 
attacks themselves are incited by various 
causes. When these causes are absent, it 
can happen, as Moebius ^ emphasizes, that 
the patient with migraine may be free 
from attacks for years or decades. 
Theoretically, it would even be possible 
that he might have no attack during his 
whole life, and that the presence of his 
disease was only expressed by its trans- 
mission to his children. 

Since we have not come to the root of 
the malady, the tendency to hemicrania, 
until to-day, it is the modest task of the 
medical art to eliminate the attacks, or at 
least to make them as light and as seldom 
as possible. 

Hitherto, also, conditions were not of 
the best in this respect. 

Eulenburg ^ expressed himself with re- 
gard to this as follows: 

" The prognosis of migraine is only a 

^ Moebius, " Migraine," in Nothnagel's Handbuch. 
^ Eulenburg, " Migraine," in Realencyklopadie, 3rd 
edition. 

213 



DIETETIC TREATMENT 

good one in so far as life is not threatened 
by the neurosis, and also as severe dis- 
turbances of the health are not, as a rule, 
brought about by it. At any rate, mi- 
graine remains for the man afflicted with 
it a very troublesome, often tormenting, 
complaint, which can only be suppressed 
in exceptional cases, which cannot always 
be relieved with certainty and restricted 
in the frequency of its appearance." 

The judgment of all who have to see 
and to advise many cases of migraine is 
very similar. 

Now, from what do the attacks come, 
what incites them? The authors are still 
not certain about this, and especially not 
in agreement. 

What seems very well established to 
one — for example, the connection of cer- 
tain attacks of migraine with menstrua- 
tion, which I and Flatau think very prob- 
able — is denied by others. This is also 
the case with another etiological crisis, 
which is of special interest to us: the con- 
nection of the attack of migraine with 
digestive disturbances. 

Tissot (1783), whom Moebius char- 
acterizes as the classic writer on migraine, 

214 



OF OBESITY 

was of the conviction that migraine comes 
from the stomach. In one of the most re- 
cent pubhcations on the subject (Eulen- 
burg, Realencyklopadie, chapter " Mi- 
graine," 1910), we find, on the contrary: 
" The frequently recurring assertion of 
the gastric origin of migraine is just as 
absurd." 

Jourdanet, who recommends slow eat- 
ing as a preventive measure, also Mathieu 
and C. Roux, and very recently Herzf eld, 
must be mentioned as the representatives 
of the opposing view. Herzf eld ^ finds 
that in a great number of cases the mi- 
graine attack results from auto-intoxica- 
tion from the intestine. He therefore 
orders a substantial restriction in the con- t 

sumption of meat, or even forbids it en- 
tirely, and places his patients upon a 
vegetable diet. Milk is permitted, but | 

is mixed with alkaline waters. Eggs are 
forbidden. The diet must not have a con- | 

stipating effect. But if it does, saline :| 

cathartics must be given daily. Alcohol ij 

and tobacco are to be avoided, as well as 
sexual and other excesses. 

^ Herzfeld, the " Treatment of Migraine," Therapeut- 
ische Monatshefte, 1908. 

215 



DIETETIC TREATMENT 

Unfortunately, the publication of Herz- 
feld contains no clinical histories which 
would be adapted to prove the therapeutic 
results asserted. 

Even the authors who deny the gastric 
origin of the attacks recommend similar 
dietetic measures, especially the avoidance 
of the immoderate eating of meat and of 
all excesses in diet. 

Flatau, who has recently published a 
monograph dealing with migraine (die 
" Migrane," Berlin, 1912), agreeing with 
several other authors, sees in migraine a 
disturbance of tissue-change. The regi- 
men which he recommends to combat it 
coincides substantially with the prescrip- 
tions which Brugsch and Schittenhelm 
consider indicated in " tissue-change 
gout." 

Flatau prescribes a vegetarian diet, de- 
ficient in purin, which is to be followed 
for months and years. Besides vegetables, 
eggs and milk are allowed. Meat, meat- 
broth, mushrooms, leguminous vegetables, 
and chocolate are absolutely forbidden. 
Tea and coffee (free from caffein) are 
permitted in restricted amount; alcohol 
and tea tabooed. 

Another author, Haig, designates vege- 

216 



OF OBESITY 

table diet as a panacea for migraine. 
Flatau, on the contrary, who, however, 
also gives his patients vegetable food, de- 
clares that he has never seen that this diet 
has completely freed the sufferer from 
hemicrania from his complaints; yet he 
has often been able to observe a material 
relief. 

The book of Flatau lacks clinical his- 
tories by which the size and significance 
of his results could be estimated. 

As will appear from the following, I 
have given my patients neither food free 
from purin, nor even that deficient in 
purin. The diet which I recommended 
contained no insignificant amounts of 
meat. And, nevertheless, there appeared 
in very numerous cases an improvement 
in their malady bordering on the miracu- 
lous. 

As already mentioned, I have arrived at 
the question of the treatment of migraine 
without intending it. The case which I 
reported has the rare pecuharity that a 
suggestive influence on the part of the 
physician could be absolutely excluded. 
I knew neither that my patient was previ- 
ously tormented by migraine, nor that she 
remained free from attacks during the 

217 



DIETETIC TREATMENT 

treatment. This is not unimportant in 
a " nem-osis " like migraine, because, as 
experience shows, even suggestion may 
restrain the attacks for a time. But this 
effect, unfortunately, does not last. 

The following clinical histories which 
report successes, lasting for months and 
years, seem to me to prove that the dietetic 
treatment, which was introduced to com- 
bat obesity, also prevented the attacks of 
migraine. 

Whether the gastro-intestinal origin 
of the irritations which excite attacks of 
migraine in predisposed subjects is 
thereby proved or made probable, let us 
not discuss for the present. At any rate, 
the patients were happy to have gotten 
rid of two maladies hy one treatment. 

As already mentioned, my material at 
first consisted only of obese patients whose 
history showed the presence of genuine 
migraine. Some examples of this kind 
may follow here. 

No. XXIV, 4, the 30-year-old wife of an 
officer, visits me on July 18, 1906, in order to 
become slimmer. Obesity and migraine are he- 
reditary in the family (cf. also the following 
clinical history) : a sister of her mother suffers 
from the most severe migraine. No sort of 

218 



OF OBESITY 

serious disease preceded. Migraine since her 
13th year; an avera^ge of two attacks a week. 
Her head is well upon awakening. The pains 
begin in the afternoon. One side of the head 
is worse — now the right, now the left. Con- 
nection with digestive disturbances cannot be 
demonstrated. Eyes and nose were examined by 
specialists and found sound. Heart and lungs 
without findings. Blood-pressure 95 mm. Hg. 
Appetite good. A moderate eater. Cramps in 
stomach often occur at 4 a.m. and last from 45 
minutes to an hour. Apparently independent 
of the kind of meal previously eaten. Bowels 
and menses regular. Patient plays tennis twice 
a week ; takes a walk lasting an hour and a half 
on other days. Smokes a few cigarettes dur- 
ing the day. Sleeps 8% hours very well. For- 
mer diet: 

Morning : Tea and one buttered roll. 

Ten o'clock: Bread and butter. 

Noon: Soup, beef or roast, potatoes or rice, 
often farinaceous food, much bread, fruit, black 
coffee, water. 

Five o'clock: Tea, bread and butter. 

Eight o'clock: Cold meat, and one egg or 
roast with potatoes, etc., much bread, water. 
The patient is strictly abstemious. 

Height, 170 cm.; weight with clothes, 81. TO 
Kg. A decrease of 8 Kg. is fixed as the goal 
of the treatment. 

Prescribed diet : 

219 



DIETETIC TREATMENT 

Morning: One cup of tea, two lumps of 
sugar, 50 Gm. of rolls. 

Noon : 200 Gm. of bouillon or Julienne soup, 
120 Gm. of beef or lean roast, 150 Gm. of green 
vegetables or 50 Gm. of sauce and 100 Gm. of 
potatoes, 200 Gm. of fresh fruit, one cup of 
black coffee with one lump of sugar, no bread, 
water ad libitum. 

Five o'clock: One cup of tea, two lumps of 
sugar, 20 Gm. of bread. 

Evening: 130 Gm. of any roast desired or 
110 Gm. of cold meat, or one ^gg and 80 Gm. 
of cold meat, 140 Gm. of cucumbers, lettuce, or 
saccharine preserves. Twice a week, roast pota- 
toes as a side dish with the roast, 200 Gm. of 
fresh fruit, 20 Gm. of bread, water ad libitum. 

Progress of the Treatment. 



Date. 


Weight. 


Remarks. 


July 18, 1906 


81.70 
79.50 
78.00 
76.60 

76.00 
74.80 

74. SO 


Beginning of the treatment. 

Euphoria. No migraine. 

Euphoria. No migraine. 

Euphoria. Menses on Au- 
gust 11th. Migraine on 
this and the following day. 

Euphoria. No migraine. 

Euphoria. September 8th, 
menses. No migraine. 

Euphoria. October 8th, 
menses. No migraine, 
also no more pains in 
the stomach. Conclu- 
sion of the treatment. 
Normal diet. 


July 26 


August 3 


August 17 


August SO 


September 11 


October 9 





220 



OF OBESITY 

Subsequent reports: 

December 13, 1906: Weight, 74.30 Kg. 
Never migraine. 

July 14, 1908: Weight, 76.85 Kg. Migraine 
extremely seldom, and only after gross trans- 
gressions in diet. Patient follows the regimen 
of the treatment again and reduces her weight. 

Also reports of most recent date announce 
that the lady is almost cured of migraine. 

It is not a question here of menstrual 
migraine. However, the only relapse 
during the treatment occurred at the time 
of the menses. 

No. XXIV, 29, the 33-year-old officer, is a 
brother of the patient whose clinical history was 
just given. Even as a boy he was too stout. In 
1901 his weight reached its maximum of 90 Kg. 
net. Somewhat decreased by " diet." For 
several months his weight has remained station- 
ary in spite of continued diet. 

Suffers from fearful migraine, which begins 
with " dazzling " ; must get to bed during the 
attack. Pains now on right side, now on left. 
Between the 4th and 17th of September (the 
day of his appearance) there were two attacks, 
on other occasions an average of one attack 
every three weeks. Feeling of hunger during 
the migraine. He believes that the attacks were 
221 



DIETETIC TREATMENT 

incited bj mental overfatigue. Every remedy 
tried, noaie helps. Heart and lungs sound. 
Stomach in order, only now and then heart- 
burn. Bowels regular. Patient walks one hour 
every day and rides one and one-half hours. 
Does not smoke, abstains from alcohol. Former 
diet: 

Morning: Tea, one buttered roll. 

Noon: Soup, meat, vegetables (never pota- 
toes), farinaceous food or entree. Mocha, fruit, 
much bread. 

Evening: Roast, side dishes or cold meat. 
Much bread, one to two cups of tea, pastry. 

Height, 184 cm. 

Regimen of treatment: 

Morning: Tea, two cups of milk, 50 Gm. of 
rolls, one ^gg- 

Noon : 200 Gmi. of beef soup with solid con- 
stituents, 160 Gm. of lean beef or lean roast, 
180 Gmi. of green vegetables, 90 Gm. of farina- 
ceous food or rice, 250 Gm. of fresh fruit, one 
cup of Mocha with one lump of sugar, no bread, 
water ad libitum. 

Evening: 120 Gm. of vegetables, prepared in 
English manner, 160 Gm. of lean roast or 220 
Gm. of chicken, or 140 Gm. of cold meat, 150 
Gm. of lettuce, cucumbers, raw sauerkraut. 
Once a week (with cold meat) 50 Gm. of bread 
and butter, otherwise no bread, 250 Gm. of 
fresh fruit, one cup of tea, two cakes. 
222 



OF OBESITY 

Progress of the Treatment. 



Date. 


Body 
weight. 


Remarks. 


October 22, 1906 

October 29 


92.0 
88.5 
88.0 

86.0 
85.0 
83.0 

86.0 


Beginning of the treatment. 

Euphoria. No migraine. 

Euphoria. Migraine once 
after a hunting dinner. 

Euphoria. No migraine. 

Euphoria. Migraine once. 

Euphoria. No migraine. 
Conclusion of the treat- 
ment. Normal diet. 

Eighteen months later pa- 
tient presents himself 
again. Migraine is al- 
most cured. Very rare, 
slight attacks. Heart- 
burn never appears again 


November 5 


November 12 


November 19 


December 7 


Decembers, 1908 



He now follows the treatment-regimen 
for two weeks and thereby reduces his 
weight 1% Kg. 

No. XIX, 44, a very intelligent woman, 
37 years old, mother of three children, the 
youngest of which is 3% years old, seeks me 
for the purpose of undergoing an obesity 
treatment. Mother and grandfather, on her 
mother's side, were corpulent. She herself 
weighed 83 Kg. until the beginning of her last 
pregnancy, and, 10 years before, 68 Kg. Has 
nursed her youngest child and has become 10 
Kg. heavier through pregnancy and nursing. 

Migraine, inherited from; her mother, since 
223 



DIETETIC TREATMENT 

the age of 10, before the appearance of the 
menses. Attacks are milder in winter than in 
summer. An attack at least every two weeks, 
always during the menses an attack. Seat of 
the pains, on the right. End in vomiting. Dura- 
tion, two days and two nights. Formerly the 
attacks came more frequently than now. 

Cause of the obesity very apparent: excess 
in consumption of bread. 

Blood-pressure, 155 mm. Hg. 

Height, 166.5 cm. 

Beginning of the treatment on February 14, 
1905, with a weight of 93.70 Kg. 

Conclusion of the treatment on June 6, 1905, 
with a weight of 78.10 Kg. and a blood-pressure 
of 118 mm. Hg. 

During the whole duration of the treatment, 
hence almost four months, not even an indication 
of an attack of migraine. 

No. XIX, 25, an unmarried lady, 45 years 
old, afflicted with migraine and obesity on her 
mother's side. Too heavy since the age of 30 ; 
weight increased 10 Kg. in the last year. Re- 
peated Marlenbad treatments. Result, 4 Kg. 
at most, with much trouble and torture. 

Very violent and frequent attacks of typical 
migraine. Recently days entirely without at- 
tr.cks are of rare occurrence. Menses regular. 
For two years repeated, genuine attacks of gout, 
with localization in the balls of the great toes. 
224 



OF OBESITY 

Increased urates in urine upon one examination, 
otherwise no pathological constituents. Consti- 
pated; uses bitter water. 

Height, 171 cm. 

Weight (with clothes) at beginning of treat- 
ment, on January 30, 1906, 107.80 Kg. At 
conclusion of treatment on May 8, 1906, 95.30 
Kg. 

During the whole period of treatment 
completely free from migraine, also ex- 
cellent health in other respects, except for 
a slight attack of gout, which occurred on 
February 27th, and was relieved in twa 
days. 

I could cite very numerous similar 
clinical histories. The rule was disap- 
pearance, or at least very striking subsid- 
ing in the intensity and number of the 
attacks; the rare exception, unaltered 
continuance. Gross infractions of diet 
were revenged by the reappearance of 
headaches. 

The purely menstrual migraine often 
did not react at all; the '* mixed " — which 
always produced attacks during the 
menses, also at other times — behaved 
differently. Complete cures in the sense 
of the entire absence of the attacks could 

15 225 



I 



DIETETIC TREATMENT 

seldom be recorded, substantial improve- 
ments often. 

It happened now and then that even 
migraine patients with normal condition 
of the nutrition and also those who might 
require fattening treatments sought me 
for the purpose of removing their tortur- 
ing headaches. They were generally rela- 
tives, friends, probably also servants, of 
my obese sufferers from hemicrania. 

I undertook to help them also by pre- 
scribing a diet. 

First of all some examples, then the 
principles which I drew from my observa- 
tions. 

No. XV, 20, the 45-year-old creative artist 
and director of a great art institute, inherited 
migraine from his mother, the latter from her 
mother. The first attacks in childhood. He 
distinguishes two kinds of attacks. 

(1) The "sudden flight." Inciting factor 
(according to his opinion), too warm bed cover- 
ing. The " sudden flight " may come at any 
time of the day, and also appears very fre- 
quently; sometimes daily. 

(S) The " severe attack." Several years 
ago this was recorded every other day; now 
more seldom, about twice a month. " Pains 
226 



OF OBESITY 

enough to drive me crazy." The patient is 
deathly pale during the attack. 

The severe attacks, he said, were incited every 
time he overloaded his stomach, also when he ate 
fat dishes, onions and other members of the 
same family. 

Hemorrhoids since the age of SO, which have 
caused very violent hemorrhages and which had 
to be operated on three times. Constipation. 
Different remedies used; the last time 50 Gm. 
of milk sugar and compound licorice powder. 

Patient is quite a heavy eater. In the evening 
he drinks a glass of beer, and wishes earnestly 
to be allowed to retain this habit. 

He is 167 cm. tall and weighs 65.60 Kg. in 
his clothes, hence rather too little. 

Diet prescribed (carried out with the scales) : 

Morning: SOO Gm. of weak coffee, 100 Gm. 
of rye bread, not fresh, possibly toasted, W Gm. 
of butter, one glass of water. 

Noon: 200 Gm. of any soup desired, 100 Gm. 
of beef or roast, 150 Gm. of green vegetables 
and potatoes, 140 Gm. of farinaceous foods, 100 
Gm. of fruit, no bread, one to two glasses of 
water. 

Five o'clock: Tea, 80 Gm. of bread and 
butter. 

Evening: 120 Gm. of roast, 150 Gm. of pota- 
toes or green vegetables or preserves, 200 Gm. 
of fruit, one-half litre of beer. 
227 



DIETETIC TREATMENT 

The most important difference com- 
pared to the earher diet was moderation 
with respect to amount. Previously the 
patient had eaten far too much, particu- 
larly at banquets, but too little at home. 

The success of my prescription was re- 
markable. 

" My husband has been a different man 
since he has taken your treatment," the 
wife of the patient reports to me. Indeed, 
he was so conscientious that he carried 
the food scales with him and made use of 
them wherever he was stopping, even when 
he was a guest. Moreover, the diet regu- 
lated the bowels; purgatives were only 
seldom necessary. 

No. XXIV, 44, the 27-year-old girl, is in the 
service of one of my patients (female). She has 
suffered' from migraine since her 15th year. In- 
herited affliction can be shown. At first the 
attacks appeared only during the menses; for 
several months they have hardly been absent. 
Hence there is a condition present which Moebius 
characterizes as " Status hemycranicus" The 
patient can attend to her professional duties 
only with great tortures, and is in danger of 
losing her daily bread. No noteworthy findings 
in the inner organs. Menses regular. Often 



OF OBESITY 

heart-burn, never vomiting, bowels in order. 
Patient goes out of doors only once in two 
weeks. 

The former diet, composed of five meals, con- 
tains abundant bread, at noon meat, in the even- 
ing sausage or two eggs. Patient has lost 
weight in the last year. She weighs 53.20 Kg. 
with clothes, and is 154 cm. in height. 

Diet prescribed: 

Morning: 250 Gm,. of coffee with milk, one 
roll. 

Ten o'clock : 80 Gm. of bread and butter. 

Noon: 150 Gm. of soup, 80 Gm. of meat, 
180 Gm. of any vegetables desired, 140 Gm,. of 
farinaceous foods, 100 Gm. of apples. 

Five o'clock: 250 Gm. of coffee with milk, 
one roll. 

Evening: Two eggs or 100 Gm. of cold meat 
or 120 Gm. of sausage, 100 Gm. of bread and 
butter, one-half litre of milk. 

With this diet she gained 2 Kg. in 
the course of two months, and now looks 
blooming. The " daily attacks " ceased 
from the fourth day of treatment, and 
slight attacks could be recorded only dur- 
ing menstruation (twice in the time under 
observation) . The heart-burn has stopped 
completely. 

I could not say whether these patients 

229 



DIETETIC TREATMENT 

took more or less food before than after 
the treatment. As is seen, the amount of 
food I allowed was considered abundant. 
The addition of fat intended also actually 
appeared. 

It is beyond the scope of this publica- 
tion to treat here in detail further cases 
of migraine which were not combined with 
obesity. Only let this be remarked for 
those who wish to continue my therapeutic 
attempts: it does not seem advisable to 
combine the treatment of migraine with 
an energetic fattening treatment, even if 
this should be indicated under other cir- 
cumstances. Let the patient be given at 
first only so much easily digestible food 
as is necessary to maintain a uniform 
weight. Let the amount of food be in- 
creased, in order to pave the way for 
a slow addition of fat, only after the ex- 
piration of several weeks. 

Eating according to the scales, hence a 
uniformity in the consumption of food 
which can only be attained in this way, is, 
according to my full conviction, the cause 
of the numerous and fine successes on 
which I look back in my treatment of 
migraine. I am not able to decide in this 

230 



OF OBESITY 

connection whether the suppression of 
overeating and the abnormal decomposi- 
tion processes in the ahmentary canal con- 
nected with it (as Frankfurter assumes) 
plays the deciding role ; or the elimination 
of occasional cases of overloading and dis- 
tention of the stomach, which doubtless 
often occur, when unlimited food is eaten. 
Both possibilities are open to discussion. 

The irritant which incites migraine, 
which proceeds from the female generative 
gland, as already mentioned, could be in- 
fluenced not at all or not materially by the 
diet. 

It is taught that the migraine attack 
can also be produced by various other 
causes; for example, pathological condi- 
tions of the eyes, nose, etc. I would be 
guilty of an unpardonable digression 
from my theme were I to go into these 
questions further here; I might also be 
able to adduce no new enlightening 
observations. 



231 



CHAPTER XXI 

Among my patients there were not a 
few who suffered from heart-burn and 
vomiting, or from one of these symptoms 
alone. These extremely troublesome 
accompanj^ing and resultant phenomena 
of hyperacidity and various stomach dis- 
eases were often the only real complaints 
of youthful obese subjects who sought me 
in order to become thin. At first they 
gave no credence to my promise to free 
them from these disturbances also. They 
had, indeed, generally consulted physi- 
cians and visited health resorts for this 
purpose without finding a permanent 
cure. 

Some examples (I could easily multiply 
the number by ten) may demonstrate 
what influence the treatment of obesity 
usually has upon pyrosis and vomiting. 

No. XXV, 3, a very famous colleague living 

in Switzerland, afflicted with gout, never 

seriously ill, had suffered from migraine until 

he became an abstainer (about twenty years 

232 



DIETETIC TREATMENT OF OBESITY 

ago). Heart-burn and vomiting, especially 
after nights with insufficient sleep. Diarrhoea 
in youth, bowels now regular. No sort of out- 
door exercise, except occasional bicycle trips ; 
no other sport. Increased in weight very 
recently, whereby his activity was impaired. 
Former diet: 

Morning: One cup of coffee with milk, 
graham bread, butter, confectionery (in large 
amount). 

Noon : Soup, roast, vegetables, dessert, much 
graham bread. 

Four o'clock : Tea with sugar. 

Evening: Meat, vegetables, fruit, one glass 
of milk, graham bread. Strictly abstemious. 

Height, 180 emu 

Weight, with few clothes, 86 Kg. 

We decide to reduce the weight about 6 Kg. 
Beginning of the treatment on October 1, 1906. 
Diet prescribed: 

Morning: 100 Gm. of milk thinned with tea 
or coffee in any amount desired, 10 Gm. of 
sugar, 50 Gm. of graham or other bread, very 
little butter. 

Noon : 200 Gm. of beef soup with very little 
solid constituents, 120 Gm. of lean roast or 
boiled beef, 180 Gm^ of green vegetables or 
lettuce or cucumbers, 30 Gm. of butter, 250 Gm. 
of fresh fruit. 

Five o'clock: Tea, 15 Gm. of sugar. 
233 



DIETETIC TREATMENT 

Evening: 150 Gm. of any roast desired, 
possibly in two courses (also fish and roast), 
160 Gm. of green vegetables or salad or cucum- 
bers or California preserves, 30 Gm. of bread, 
250 Gm. of fresh fruit, tea, 15 Gm. of sugar, 
water always ad libitum. 

This diet, followed with the greatest 
conscientiousness, reduced the weight to 
79.4 Kg. in six weeks. 

Vomiting and heart-burn disappeared 
entirely from the first day of the treat- 
ment; also, no vomiting, no heart-burn 
during the normal diet, which was con- 
sidered abundant. 

Four years later I saw my colleague 
again. He remained free from ailments 
and also kept his weight continually at the 
low level which it had reached. 

No. XXXV, 23, a merchant, 28 years old, 
187 cm. in height and weighing 114 Kg. (with 
clothes), sought me in 1909 for an obesity 
treatment. Very heavy eater, chiefly of bread. 
Has suffered for years from torturing heart- 
burn, at times also from vomiting. A capable 
Vienna physician found him entirely sound, sup- 
posed the cause of his ailment to be the abuse 
of tobacco, and forbade him this. 

Patient stopped smoking. But the heart- 
234 



OF OBESITY 

burn became almost imperceptibly less. There 
fore he began to smoke again some months later. 
Another physician advised him to eat less. 
Patient endeavored to follow this advice; but 
since he received no definite directions as to what 
food was allowed and what forbidden, and since 
he ate rather more than less in doubtful cases, 
as the great majority of men do in a similar 
position, this order, correct in the main, also 
failed to attain its end. 

Heart-hum and vomiting ceased com- 
pletely from the hour when he followed 
the regimen I prescribed with the help of 
the scales. 

After a treatment of two months, which 
reduced his weight 7 Kg., an acute gas- 
tritis appeared as the consequence of a 
fish poisoning. At the expiration of this, 
the patient was '' well nourished," at the 
wish of his family physician, in order to 
recover more quickly. Immediately the 
heart-burn appeared again, but disap- 
peared on the day when the directions of 
the treatment were followed once more. 

No. XXV, 13, the 36-year-old wife of a 
merchant, had contracted catarrh of the stomach 
six years ago, which lasted two years. The ap- 
petite is good now. Violent heart-burn and 
235 



DIETETIC TREATMENT 

vomiting almost daily. Patient is 166 cm. tall 
and weighs 86.90 Kg. Is to reduce from 10 to 
12 Kg. Still a little heart-burn at the expira- 
tion of the first week of treatment, but no more 
at the expiration of the second week. Vomiting 
very seldom. After a treatment lasting nine 
weeks, patient is dismissed with a weight of 
76.10 Kg. and entirely free from afflictions. 

In this case the influence of the regunen 
of the treatment upon the two disturb- 
ances which concern us here did not ap- 
pear at once, which is probably to be 
traced to a more deep-seated disease of the 
stomach, which was still present at the 
beginning of the treatment. 

No. XLIII, 47, the 34-year-old musician, 
is 180 cm. in height and weights 95 Kg. (with 
clothes) ; has suffered from j^outh with cramps 
of the stomach and from unbearable heart-burn 
and vomiting after almost every meal. These 
disturbances are familiar. One of the most dis- 
tinguished physicians in Vienna establishes a 
diagnosis of hyperacidity of high degree, and 
prescribes a diet according to the scheme: This 

is forbidden ; this is allowed . 

No success. Patient consumes daily 10 hellers' 
worth of bicarbonate of soda. On January 14, 
1913, he seeks me for an obesity treatment. 



OF OBESITY 

Still heart-burn. Only on the first day of the 
treatment. From then on traceless and per- 
manent removal of the tormenting symptoms. 
The decrease in weight progresses according to 
schedule. On March 8th weight still amounts 
to only 88.30 Kg. 

I could cite similar clinical histories in 
great number, but I believe that my 
readers would learn no more from them 
than from those already referred to in 
abstract. The same thing is always re- 
peated: men who eat much (especially 
bread) become obese and complain of 
heart-burn and vomiting. They have 
already tried many things, visited health 
resorts, etc., without permanent success. 
They feel free from symptoms during 
their residence in Carlsbad ; but on the re- 
turn journey, perhaps even in the dining 
car, they have to draw forth their soda 
box again in order to quiet the burning in 
their stomachs. If these men are sub- 
jected to an obesity diet and later to a 
normal diet, according to the scales, they 
remain permanently free from symptoms. 

The supposition, absence of serious 
diseases of the stomach, generally proves 
correct in the case of our patients, since 

237 



DIETETIC TREATMENT 

these do not usually occur in connection 
with the addition of fat. 

There would be nothing more absurd 
than to believe that every case of pyrosis, 
etc., can be healed so easily. The phe- 
nomena may also accompany diseases 
which are serious or difficult to cure. 

But, on the other hand, it may also 
occur that men who eat too much get 
heart-burn and vomiting, but put on no 
fat. Even these can be cured immediately 
by a single regimen, measured out quanti- 
tatively. 

No. XLI, 11, the 35-year-old merchant, is 
the brother of a patient (female) whose weight 
I reduced 20 Kg. He was never seriously ill. 
Torturing heart-burn and noisy eructation have 
occurred after every meal for two years. Bowels 
regular without cathartics. Pains in the region 
of the stomach and vomiting could never be 
recorded. Examination of the inner organs 
without findings. Has consulted many phy- 
sicians without success. Was also in Marienbad 
without being cured. 

Patient is a heavy eater. The food is poorly 
chewed and hastily swallowed. 

Height, 171 cm.; weight (with clothes), De- 
cember 28, 1911, 80 Kg. 

238 



OF OBESITY 

Patient wishes, above all, to be freed from 
his complaints. A slight reduction in weight 
was at the same time comprised in the bargain. 
First a mild obesity diet is prescribed, then the 
following normal diet: 

Morning: WO Gm. of coffee with cream, one 
lump of sugar, 60 Gm. of rolls, two eggs or 
50 Gm. of ham. 

Noon: 150 Gm. of soup with solid constitu- 
ents, 120 Gm. of beef or roast, 150 Gm. of 
spinach, boiled lettuce, carrots, green peas, 
green beans, potatoes or 100 Gm'. of rice, 
macaroni, noodles, 120 Gmi. of farinaceous foods, 
150 Gm. of fresh fruit, one glass mineral water, 
no bread. 

Five o'clock : 200 Gm. of coffee and 40 Gm. 
of rolls. 

Evening: 150 Gm. of roast or fish or 220 
Gm. of roast poultry, 150 Gm,. of vegetables as 
at noon, or salad or preserves, 150 Gm. of fresh 
fruit, no bread. 

Within three weeks the weight was reduced 
2.50 Kg., then it stopped. 

Since the beginning of the treatment 
neither heart-burn nor vomiting. Only 
on two days, when the patient disre- 
garded the rules, both disturbances ap- 
peared again. 

I have at my disposal only a few 

239 



DIETETIC TREATMENT OF OBESITY 

observations on those who are not obese, 
but I am convinced that a restriction of 
the amount of food down close to the 
actual requirement, as recorded by the 
scales, would bring relief to many a 
patient of this kind. Whether a qualita- 
tive choice of food and a prohibition of 
dishes, which, according to experience, 
cause heart-burn and vomiting, or which 
the patient designates as harmful to him- 
self, will be necessary every time, I do not 
know. That will have to be decided from 
case to case, possibly even by a trial. My 
obese heavy eaters could generally stand 
without trouble even the dreaded vege- 
tables rich in cellulose, the varieties of the 
cabbage family. In their case the heart- 
burn and vomiting were caused almost 
without exception by excess of food alone. 



240 



CHAPTER XXII 

Just as many others before me, I, also, 
could not rid myself of the impression 
that the tendency to put on fat increases, 
or, at any rate, first begins, with the ap- 
pearance of the climacteric. Not infre- 
quently I had the opportunity of treat- 
ing women who were laboring from 
climacteric flushings and sweatings. 

These phenomena had for me at first 
only the significance of a topic which had 
no reference to my field. I had heard 
again and again complaints about the con- 
ditions and about the futility of all 
therapy. Ovarian preparations were 
tried in many cases, without any result. 
This remedy may have been at times suc- 
cessful. But no such case was found 
among the many women whom I have 
observed. They were all more or less 
obese. Perhaps that was the cause: per- 
haps the preparations are eiFective only 
in the case of thin people. To the joj'^ 
of the patients, in which I took a lively 
interest, and, as I wish to confess openly, 
unexpectedly and almost unintelligibly to 
me, in the majority of cases the two most 

16 241 



DIETETIC TREATMENT OF OBESITY 

disagreeable symptoms entirely vanished 
with the beginning of the treatment, or 
were reduced to a very endurable degree. 
In the beginning I did not connect the 
treatment with the ceasing of the flush- 
ings. Of course, the flushings cease at 
some time in the case of every woman, and 
it might have happened that they ceased 
just at the time when my treatment be- 
gan. But, since the temporal coincidence 
was always repeated ; since, finally, I could 
predict the effect, as in an experiment; 
since the eiFect seemed to be independent 
of the duration of the disturbances; and 
since it could also be recorded when the 
flushings first made their appearance; 
and, above all, since the two symptoms 
came again when the nutriment according 
to the treatment was interrupted for any 
reason, I now consider a causal connection 
between treatment and abatement of the 
climacteric -flushings extremely probable. 

This influence was also present in the 
artificial climacteric which was caused by 
the removal of both ovaries. 

I was never in a position to test whether 
the flushings, etc., could be made to dis- 
appear by the effect of a certain diet even 
in the case of those who were not obese. 

242 



CHAPTER XXIII 

As IS well known, and as I have already 
mentioned in another place, obesity and 
disturbances of menstruation frequently 
occur in combination. The cases of 
myxoedema, of diseases of the hypophysis, 
of typus adiposo-genitalis (Alfred Froh- 
lich), need not be considered in this con- 
nection. We are interested here only in 
the case of otherwise healthy girls and 
women who were either obese from youth 
on, and who never or very seldom men- 
struated, and others whose menstruation, 
previously regular, returned only at great 
and irregular intervals, or stopped en- 
tirely from the time when obesity had 
reached a certain height. 

The amenorrhoea and the sterility con- 
nected with it which obese women have 
form an indication for reduction, recog- 
nized even by the opponents of obesity 
treatments. And with good reason. 

A regulation of the menses appears, in 
the course of the reduction of weight, in 
a very considerable fraction of cases. But, 
while the influence of the treatment upon 

243 



DIETETIC TREATMENT 

blood-pressure, migraine, and the climac- 
teric flushings can be recorded almost 
always in the first days, when enormous 
quantities of fat are present, menstrua- 
tion first appears or becomes regular only 
when a considerable loss of weight is at- 
tained, often only after months. 

On the other hand, heed is to be paid 
to the fact that it is not always prodig- 
iously obese women who sufl*er from men- 
strual disturbances. Some examples may 
illustrate what has been said. 

No. XXXVIII, 27, a 17-jear-oldJ girl of 
radiant appearance, in sound health, 167 cmi. in 
height and weighing 83.70 Kg. with clothing, 
presents herself to me on October 1, 1910, for 
reduction. First menses at the age of 14. In- 
tervals of several months. The last menstruation 
appeared in May, hence more than 4 months 
ago. 

The treatment took its normal course. 
From the time when the weight has sunk 
7 Kg, the menses appear at regular 
monthly intervals. 

No. XXXIX, 26, the 32-year-old wife of a 

colleague, 161 cm. in height and weighing 75.10 

Kg. with clothing. Menses irregular, about 

every 6 weeks. The weight is reduced to 66 Kg. 

244 



OF OBESITY 

Since then — two years — the menses ap- 
pear at monthly intervals with absolute 
regularity. 

No. XII, 4, the 30-year-old wife of an 
official, mother of an 8-year-old child, 152 ( !) 
cm. tall, weighs 82.90 Kg. (with clothing), 
hence very obese. Menses only every 4 to 6 
months. Presented herself to me June 28, 1905. 
Her weight is reduced about 8 Kg. Menses 
become regular from, that time on, and remain 
so for one year. Then the patient interrupts 
the dietetic treatment. She becomes heavier, 
menses badly retarded. No menses fromi July 
to December 2, 1908. A new treatment. 
Menses appear once, and then pregnancy, which 
ends with an abortion (March 22, 1909). 

The treatment is now continued. The 
menses appear twice at normal intervals, 
then a new, very-much-desired pregnancy, 
which is carried out to its normal end. 

It is no very unusual occurrence for 
women who had remained sterile many 
years to become pregnant during or aftei 
an obesity treatment. 

No. XXXIII, 8, a 30-year-old officer's wife, 

had been pregnant but once, 8 years ago. She 

fell ill with penumonia. Abortion in the third 

month. Then pregnancy appeared in connec- 

245 



DIETETIC TREATMENT 

tion with a " hunger treatment " which made 
the woman lose 5 Kg. Since then steady increase 
in weight. Height, 160 cm. ; gross weight on 
July 14, 1908, 81.85 Kg. Pale appearance. 
Menses, always irregular, now much delayed; 
last in January. Since then merely " traces." 
Suffered before from migraine; now less. 
Hearty eater. Five meals a day. Much bread. 
Blood-pressure, 140 mm. Hg. 

On November Snd, patient is dismissed with 
a weight of 63.05 Kg. The decrease amounted, 
therefore, to 18.80 Kg. She now looked much 
better, had entirely lost the migraine. The 
blood-pressure had sunk to 120 mm. 

Menses on August 6th, hence still during 
treatment; after that no more. We had re- 
ferred this to the amenorrhoea which had existed 
for a long time. Wrongly! Without any one 
suspecting it, the woman was pregnant. On 
December 4th, a day of tremendous excitement, 
since her husband fell seriously ill and had to 
be operated on at once, abortion appeared in 
the fifth month. 

On April 20, 1909, I saw the woman again 
for the last time. Blooming appearance. 
Weight, 66.30 Kg. Menstruation had become 
entirely regular. 

The case now following, of very recent 
date, is instructive in two directions. It 
is a *' great " treatment, at the same time 

246 



OF OBESITY 

one of quite rapid progress, which I wish 
to describe somewhat more in detail. We 
will see at the same time the regulation 
of the menses after a radical reduction in 
weight has taken place. 

No. XLI, 19, the 22-year-old student 
(female) of philosophy, is doubly burdened with 
obesity. Too heavy even as a child. Scarlet 
fever at the age of 17 ; rapid increase of weight 
during convalescence. Diphtheria and measles 
as a child, otherwise healthy. Migraine once to 
twice a month, not menstrual. Perspires very 
heavily and then takes cold easily. For a year 
she has not been able to walk quickly nor dance. 
In that case dyspnoea, not palpitation, ap- 
peared. Stomach good, bowels constipated. 

Menses often absent many months. First 
menses at age of 13. Now cessation of a year. 
Appearance blooming. Gynaecological find- 
ings, upon rectal examination, made by Profes- 
sor Mars in Lemberg, show normal conditions. 

Patient now walks very little. I prescribe for 
her at first a daily walk of half an hour; later, 
if the desired activity shall have appeared, one 
of one to one and one-half hours every day. 

Sleep, 9% hours, to be continued during the 
treatment. 

Former diet: 

Morning: Tea, two rolls. 

Ten o'clock : Bread and 30 Gm. of ham. 
247 



DIETETIC TREATMENT 

Noon: Soup, meat, vegetables (many pota- 
toes), bread, water as drink. 

Four o'clock: Tea, one roll. 

Eight o'clock: Roast, many potatoes or cold 
meat and bread, tea. 

Patient likes dainties. Eats no more than 
companions of her own age. 

Blood-pressure, 100 mm. Heart and other 
inner organs without findings. Analj^sis of 
urine shows normal conditions. 

Height, 162 cm. ; weight with clothing, 121.50 
Kg. 

A decrease of 30 Eg. is fixed as the goal of 
the treatment. The diet, found suitable after 
some alterations, was composed as follows : 

Morning: Tea with saxin, 40 Gm. of rolls. 

Ten o'clock : 100 Gm. of fruit. 

Noon: 150 Gm. of bouillon, 90 Gm. of beef 
or roast or 140 Gm. of chicken, weighed with 
the bones, 170 Gm. of vegetables, namely: 
spinach, kale, boiled lettuce, cabbage, cauli- 
flower, green or yellow string beans, green peas, 
Swedish turnips or red beets (pickled), 200 Gm. 
of fruit, apples preferred, no bread, water ad 
libitum. 

Five o'clock : Tea with saxin, 40 Gm. of rolls. 

Evening: 120 Gm. of roast or other lean 
meat dish, 120 Gm. of cucumbers or lettuce, 150 
Gm. of fruit, tea with saxin ad libitum. 

Also recommended for supper: 500 Gm. of 
sour milk and 40 Gm. of bread. 
248 



OF OBESITY 

Progress of the Treatment (in Abstract). 



Date. 


Weight 

with 
clothing. 


Remarks. 


February 4, 1912 

February 11 


121.50 
119.20 

115.50 

112.50 

108.30 

104.90 
103.80 

99.80 
96.20 

94.40 

91.40 


Beginning of the treatment. 

Euphoria, no hunger, good 
sleep, no migraine. 

Euphoria, no hunger, good 
sleep. No migraine. 

Good health, except for 
very slight headaches in 
the last two days. Two 
spoonfuls of aqua levico 
fort, prescribed. 

Good health, no migraine. 
Patient begins to take 
gymnastics, Miiller sys- 
tem. 

Perfect health, no migraine. 

Appearance of menstrua- 
tion on April 18th. Mi- 
graine on this day. 

Euphoria, no migraine. 

Menstruation and migraine 
on May 25th; otherwise 
good health and no mi- 
graine. Rowing-bath 
prescribed {cf. Chapter 
xxiv). 

Perfect health; very slight 
headache once. Daily 
rowing-bath of 22° C. 
and 15 minutes' duration 
taken with great enjoy- 
ment. 

Euphoria. 


February 26 . 


March 11 


March 25 


April 7 


April 21 


May 6 


May 25 


June 9 


June 23 





Therefore the goal is reached. The 
patient has lost 30.10 Kg. On June 28th 
she presents herself to me again. Bloom- 

249 



DIETETIC TREATMENT 

ing appearance. Figure not to be recog- 
nized. Weight would be estimated lower 
than it is. Can now walk for hours at a 
time, also climb without feeling any 
trouble. Actual migraine was present 
only at the time of the menses, which have 
occurred twice at normal intervals. 

Examination of the heart shows abso- 
lutely normal conditions. Pulse 76, nor- 
mal sounds, cardiac dulness not extended, 
blood-pressure 100. 

Apropos of this case, let me touch upon 
one more question which is often put. 

Not the slightest trace of folds or 
wrinkles can he detected in the face of 
the patient. 

These never appear in individuals who 
are less than 35' to 40 years old, not even 
in the case of still more radical reductions. 
The complexion of a 28-year-old lady 
whose weight had been decreased from 
135 Kg. to 75 Kg. (hence by 60 Kg.) 
under my guidance remained that of a 
young, blooming girl. 

In the case mentioned here also no de- 
formation of the breasts occurred. These 
had not been by nature too large and the 
seat of great masses of fat. 

250 



DIETETIC TREATMENT OF OBESITY 

The patient is to undertake a holiday 
journey to Switzerland. She is going to 
make there easy mountain trips with my 
permission and with all the precaution 
ordered. The patient announces on June 
13, 1913, that her menses appear regu- 
larly. Weight, 89.30 Kg. 



251 



CHAPTER XXIV 

As already set forth and established in 
our earlier chapters, I no longer look upon 
the increased consumption of fat by 
muscular exercise as the most important 
and most effective part of an obesity 
treatment. But it would be false and 
foolish to dispense with the support which 
muscular exercise in its various forms can 
offer us. The albuminous content of the 
organism is protected most securely by 
muscular exercise. But also for educa- 
tional reasons I require my patients to 
take a brisk walk out of doors daily, last- 
ing at least an hour, unless they hitherto 
have been entirely incapable of this. The 
task is often increased to two hours, 
seldom more. Often, when there is dan- 
ger that walking will degenerate into 
creeping, I prescribe a certain number of 
steps (to be recorded with the pedometer) . 
Six thousand steps should be taken in an 
hour. Or I order the patient to cover a 
certain distance (4% to 5 km. in an hour) . 

The more precise the prescription the 
more certain can we be of its exact observ- 
ance. 

252 



DIETETIC TREATMENT OF OBESITY 

Young patients with perfect hearts, 
normal blood-pressure, and without ex- 
cessive obesity may also take mountain 
trips, in which emphasis is placed upon 
the gradual increase of the task, if the men 
are not already trained. When rambles 
are undertaken only now and then, Sun- 
day for instance, I grant the patient addi- 
tions to his diet, as already noted. 

Young men with sound hearts should 
practise sports. Rowing, cycling, riding, 
tennis, golf, fencing, gymnastics, also 
gymnastics in the room, for example, 
according to the Miiller system, and 
finally, turning of the ergostat, are recom- 
mended. This graduated form of muscu- 
lar exercise is adapted for men who can 
carry out no other muscular exercise, on 
account of age or occupation. 

On the other hand, sports which impose 
maocimum demands upon the heart (foot- 
ball, strenuous athletics, cycling up moun- 
tains, and with great exertion, especially 
racing) should be omitted during the 
period of treatment. 

I value swimming most of all forms of 
sport. It has a two-fold usefulness: On 
the one hand, as a very complete gym- 

253 



DIETETIC TREATMENT 

nastic exercise which occupies the whole 
muscular system; on the other hand, as a 
withdrawer of heat. By the contact of 
the skin with water, which is a good heat 
conductor, the organism parts with a 
large amount of heat during the bath. 
This must be equalized by increased oxida- 
tion, resulting from the combustion of the 
body fat. 

Since swimming-baths are not always 
and everywhere at our disposal, I invented 
a substitute in 1904, which proves very 
satisfactory — the " rowing-bath." A copy 
of my publication on this subject may 
find a place here. 

The Rowing-Bath 
( das ruderbad ) ( blatter fur klinische 

HYDRGTHERAPIE, Nr. 6, 1904) 

A cold swimming-bath incontestably 
belongs to the great enjoyments of life in 
the hot summer days. It refreshes body 
and mind, makes both capable of work 
and of enjoying work. The paralyzing 
effect of heat is banished, appetite stimu- 
lated, and sleep made sounder. 

There is certainly no perfect substitute 

254 



OF OBESITY 

for the swimming-bath. But this ought 
not to prevent us from seeking at least 
a partial substitute. The swimming-bath 
itself is at the disposal of only few, when- 
ever they require or desire it. 

Every healthy man can stay from 15 
to 30 minutes in water of 20° C. (16° R.) 
when swimming without suffering from 
cold. We feel extremely uncomfortable 
in a tub-bath of 20° C. after a few min- 
utes, and it certainly requires some hero- 
ism to stand it for a half hour. 

The causes of this difference are often 
obvious. We accomplish muscular eooer- 
cise in the swimming-bath, we do not in 
the tub-hath. Heat is produced as a by- 
product in muscular work. This, for the 
most part, is again given off through the 
skin, partly also through the lungs. At 
the same time, more blood streams through 
the vessels of the skin, the skin becomes 
warmer, the difference between its tem- 
perature and that of its surroundings be- 
comes greater, and the loss of heat, which 
keeps pace with this difference, is like- 
wise increased. The increased production 
of heat and its loss during exercise can be 
perceived subjectively as a feeling of 

255 



DIETETIC TREATMENT 

warmth, which doubtless proceeds from 
the end organs of the heat-perceiving 
cutaneous nerves. 

Conditions are the reverse in the cold 
tub-bath. The loss of heat is substantially 
increased by reason of the better thermal 
conducting power, even if the temperature 
of the water is higher than that of the 
air in which we move at other times, wear- 
ing clothes which are poor conductors of 
heat. The heat regulation becomes active 
while the blood current through the skin 
is cut off, the temperature of the skin 
lowered, the difference between the skin 
and surrounding medium diminished. 
Perception of cold appears subjectively, 
which finally is also a heat-regulating 
process, since it causes us to end the abnor- 
mal condition by hastening from the bath. 

Still another difference between the 
cold swimming-bath and the cold tub- 
bath deserves to be noticed. Our body 
moves through the water in swimming. 
The tactile impression which is caused by 
the water gliding over our skin is agree- 
able. It heightens the enjoyment of the 
bath, the more powerful it is, — that is, the 
more quickly the water moves forward 

256 



OF OBESITY 

over the body or the body through the 
water. 

These components have an especially 
refreshing effect if the water is alternately 
quiet and in vigorous motion, and particu- 
larly if an occasional dousing of the part 
of the body which is outside the water fol- 
lows at the same time. The ideal of the 
cold hath is the sea-bath with the surge 
of the waves. 

The work accomplished in the cold bath 
does not always have to be expressed in 
the motions of swimming. Aside from 
the stamping and squirming by which 
non- swimmers instinctively render their 
long stay in the cold river- or sea-bath 
possible, there is another natural form of 
the kinetic bath, which deserves short men- 
tion: the river-bath — the bath in swift 
moving water. (In Vienna there are such 
baths in the Danube.) 

The work accomplished in the river- 
bath consists in the anchoring of the body 
with the hands and feet, in movements of 
resistance against the surging of the 
water, and in laborious walking backward 
and forward along a rope or the railing 
enclosing the bathing basin. The rapid, 

17 257 



DIETETIC TREATMENT 

yet irregular, jerky motion of the water 
forms the chief charm of this refreshing 
kind of bath. 

On the basis of the experiences and 
considerations stated, I have undertaken 
to create conditions in the tub-bath similar 
to those found in the swimming- or in the 
river-bath. 

Permit me to describe the stages by 
which I arrived at the goal. 

At first I attempted to accomplish the 
necessary exercise as it is done even now 
in the " half -bath " : by rubbing the body, 
also by splashing and by stirring up the 
bath water with the palms of the hands. 
It was soon shown that this form of 
activity is unsuitable. The rate of the 
movements must be very fast in order to 
produce the amount of exercise necessary 
to banish the feeling of cold. For every 
single movement requires but little 
energy. 

But one soon becomes tired by the 
quick, squirming movements, carried out 
by a few small muscles, without proper 
resistance, and the bath ends prematurely. 

I now endeavored to find a form of 
movement which is similar to the move- 

258 



OF OBESITY 

ments of swimming, at least in rhythm. 
The latter, which occupies almost all 
groups of muscles symmetrically, for 
obvious reasons could not be carried out 
in the bath-tub, but there is another form 
of exercise which is likewise extremely 
suitable: the movement of rowing. 

Numerous groups of muscles are like- 
wise brought into play with the bending 
forward and backward of the upper body 
in rowing. 

Every healthy man quickly learns to 
carry out these or similar movements from 
15 to 30 minutes without interruption, 
without becoming tired. 

The movement itself, in order to be use- 
ful for our purpose, must represent a 
greater accomplishment of work, hence 
must overcome an obstacle. 

I accomplished this by stretching an 
elastic tube about 2 metres long which 
formed a loop and was fastened to the foot 
of the bath-tub. 

The bather grasps the middle of the 
tube with both hands and stretches it by 
bending back the upper body and draw- 
ing up his hands to his chest. Then he 
bends forward again from his hips and 

259 



DIETETIC TREATMENT 

stretches his arms out horizontally, where- 
upon the tube is shortened to its natural 
size again. 

Very recently I found at last a still 
simpler form of exercise, which offers a 
special advantage compared to the other. 

The necessary apparatus ^ consists of a 
little board 25 cm. long, 11 cm. broad, and 
1 cm. thick, which has on the middle of 
both narrow sides 2 cylindrical shaped 
handles. 

A thermometer, attached to the middle 
of the board, makes the continual observa- 
tion of the temperature of the water 
possible. 

Rowing movements are carried out with 
the board. The bather grasps the grips, 
bends forward and draws it through the 
water up to his breast. Body, hip, and 
arm muscles must take part in the work 
done. Not more than 20 to 25 of such 
rowing movements should be carried out 
per minute. Let every single movement 
be made " accelerando," the beginning 
slowly, the end more quickly. At the 
beginning the anterior surface of the board 
stands perpendicular, but it is then turned 

^ For sale by J. Friedl, Vienna I, Schulerstrasse Nr. I. 
260 



OF OBESITY 

up a little in order to hurl a small breaker 
against breast, neck, and head. 

I have the return of the oar to the first 
position carried out through the air with- 
out resistance. Thus there is gained, on 
the one hand, the " recovery phase," which 
is felt at every movement very agreeably; 
on the other hand, the stream of water 
which the movement of the board pro- 
duces is not disturbed. 

The powerful movement of the water 
gives an advantage to this form of bath 
which it shares with the swimming-bath 
and the river-bath. The significance of 
the streaming water has also been very 
recently recognized by others. 

Bathing mechanisms are manufactured 
in which the water is set into circulation 
with the help of a paddle-wheel turned by a 
motor.^ 

The temperature of the bath is made 
dependent upon the individual taste of 
the bather. It is agreeable if the water is 
not too cold in the beginning. As soon as 
the skin is moistened the bath can be 

^ It would be no difficult technical task to increase the 
rapidity of the water's movement. A paddle-wheel 
could be fastened to the upper edge of the bath-tub in 
the place of the rowing board, and this could be turned 
by the bather by means of connecting rods. 
261 



DIETETIC TREATMENT 

quickly brought to the desired temperature 
by running in cold water. The cold water 
should, if possible, run in at the bottom 
of the foot end. In case of need it can be 
guided with the aid of a tube. 

A rowing-bath in practice is carried out 
as follows: 

The tub is half filled with water at 30'' 
C. ( 24 ° R. ) . The bather gets into the tub 
and as near as possible to the head end in 
order to have sufficient room for his move- 
ments, grasps the rowing board, and car- 
ries out the movements described. Now 
the cold water is turned on in a quick 
stream. (If the tub becomes too full, the 
water must, of course, be let out.) 

When we are dealing with sound, 
strong men, the temperature can be 20° 
C. (16° R.) and under. I myself have 
repeatedly bathed at 16° C. (i2.8° R.), 
and remained in the bath 25 minutes. 

A somewhat higher temperature and 
shorter time for bathing is recommended 
for men with deficient blood supply and 
sensitive constitution. 

The effect of the hath, as perceived sub- 
jectively, is identical with that of a swim- 
ming-hath of the same temperature. 

Every disagreeable sensation of cold 

262 



OF OBESITY 

is absent during the bath. On the con- 
trary, we can work ourselves warm even 
in very cold water, so that the need of an 
occasional cooling off of the head and 
upper body by a cold douche or shower 
is felt. If the exercise is not overdone, 
we can bring our body into an extremel}^ 
comfortable condition on the sultriest 
day. We have the agreeable sensation of 
abundant muscular exercise without the 
disagreeable one of heating, which other- 
wise accompanies it. At the same time, an 
agreeable cooling of the skin is felt with- 
out the disagreeable shudder which 
usually forces us to interrupt a cold tub- 
or douche-bath quickly. 

After the hath, even when the tempera- 
ture of the air is very high, we feel in- 
vigorated and refreshed for many hours. 

The sweat secretion is interrupted, the 
skin remains cool and dry. 

The bath is a powerful stimulant to the 
appetite, and doubtless also promotes 
sleep. 

A more detailed report of the changes, 
which can be shown objectively, will be 
given later. I will only state a few 
particulars here. 

The temperature of the blood, measured 

263 



DIETETIC TREATMENT 



in the rectum, was 7iot influenced by a bath 
at 20"" C, lasting 20 minutes. This find- 
ing agrees with that of Winternitz, 
Tschurtschenthaler, and Tripold.^ They 
maintain firmly that a cold swimming- 
bath in the sea also exerts no material 
effect upon the temperature, if the muscu- 
lar exercise expended is not excessive. 

On the contrary, the authors mentioned 
observed an increase of the blood-heat of 
1° C. with a very low temperature of the 
water, when great muscular exertion was 
caused by high waves. On the other hand, 
I was easily able to demonstrate the cool- 
ing off of the surface of the skin. With 
the aid of a new method ^ which I devised, 
I measured the temperature of the skin 
of the back and of the palm of the hand 
and found: 



Skin temperature < 


of the palm 
of the hand 


of the back 
of the hand 


Before the bath 


34.5° 

27.2 
27.5 


33 4° 


Rowing-bath of 18° C, lasting 20 min- 
utes 




30 minutes after the bath 


27.5 


65 minutes after the bath 


28 







' Zeistschrift f . klin. Hydrotherapie, 1900, vols. 4 and 
5, and 1902, vol. 2. 

* " A Simple Method of Measuring the Temperature 
of the Skin," Miinch. med. Wochenschr., 1905, Nr. 39. 
264 



OF OBESITY 

The cooling effect of the bath finds ex- 
pression in these figures. Sixty-five min- 
utes after leaving the bath, the skin of the 
two places measured was still 7.0° C. and 
5.4° C, respectively, cooler than before. 

Twice I attempted to determine the 
amount of heat which was given off in the 
water. I chose for the attempt days on 
which the temperature of the air in the 
bath-room was almost equal to the tem- 
perature of the bath, so that the warming 
of the bath water had to depend exclu- 
sively on the heat given off by the bather. 

Two-hundred and thirty litres of water 
were warmed in 25 minutes from 16.0° C. 
to 17.0° C. Consequently the man weigh- 
ing 75 Kg. has given off in the bath water 
230 calories in the time mentioned. The 
sustained, intense movement of the water 
certainly effected an equable distribution 
of the temperature and the removal of [jO 

an error otherwise feared. 

That the cold swimming-bath signifies 
a powerful stimulant to tissue-change has 
already been emphasized by Winternitz 
and his coworkers in the publications 
cited. The same thing is doubtless true 

2C5 



DIETETIC TREATMENT 

of the rowing-bath, which is analogous, 
physically and physiologically. 

I have myself made use of the rowing- 
bath until now as a means of refreshing 
and hardening, and as a stimulant to 
tissue-change, but I believe that it can 
also be turned to a wider account thera- 
peutically. 

Two hundred and thirty calories form 
about 10 per cent, of the daily exchange of 
a man of medium weight, and are of 
great importance in our treatment. A 
swimming- or rowing-bath can hasten the 
rate of the decrease in weight materially. 

We desire such a support especially in 
the warm season, in which the quota of the 
tissue-change, which is concerned with the 
maintenance of the temperature of the 
body, sinks, and, as a result, the daily 
decrease in weight, with the same diet, is 
less than in winter. It is doubly agreeable 
because it does not involve restriction of 
diet and because it takes the form of a 
refreshing exercise. 

All hydropathic treatment which ex- 
tracts heat works like the swimming- and 
rowing-bath, even if not as energetically. 

266 



OF OBESITY 

There is nothing to be said against their 
use, especially if they are indicated for 
other reasons. 

Swimming- or rowing-baths must be so 
fitted into the order of the day that they 
immediately precede a hearty meal. The 
lively appetite which they excite should 
be promptly satisfied. 

Warm tub-baths have no particular 
effect upon the treatment. Let each one 
bathe as often as he is accustomed. 

Sweat-baths of every kind (steam- 
baths, hot-air-baths, electric-light-baths) 
are not in themselves reducing agents, but 
act only by inducing perspiration and thus 
extracting water from the organism. 
Therefore they are unsuited to our pur- 
pose. If of long duration, they may even 
retard tissue-change by storing up heat. 

Therefore I do not prescribe them in 
pure obesity treatments, but ( see Chapter 
V) when oedema is present. In these 
cases they are useful. 

If, however, a patient has been accus- 
tomed to visit the steam-bath once or 
twice a week, and wishes to continue this 
exercise, I do not interfere with him. The 
steam-bath is followed by cold douclies, 

267 



DIETETIC TREATMENT 

sometimes even by a full-bath in cold 
water or by a cold swimming-bath. These 
constituents of the sweat-bath, as is 
already shown, can also be of use to our 
patients. 

During sleep, and even in the muscular 
repose induced by the horizontal position, 
tissue-change is lowered. 

A man will burn up more fat with the 
same nutriment and 8 hours' sleep than if 
he slept 12 hours, and substantially more 
than if he kept to his bed continually. 
Hence tissue-change could be increased 
by curtailing sleep. But without exerting 
an influence upon the diet at the same 
time, a substantial reduction of the fattj^ 
content cannot be attained. I make, how- 
ever, only cautious use of the restriction 
of the period of sleep in order to " sup- 
port " the dietetic treatment. 

The need of sleep varies very much with 
the individual. We hear and read that a 
few hours of rest were sufficient for the 
heroes of intellect. Other men just as 
great had to sleep 9 hours in order to 
maintain their full intellectual powers. 
And it is the same with average men. 



OF OBESITY 

This is not the place to enter into a 
general discussion of the correct or per- 
missible length of sleep. It only inter- 
ests us in so far as we must give advice 
or directions to our obese patients. 

The standpoint at which I have arrived 
on the basis of much experience is : 

If occupation and habits of life permit, 
patients may sleep 9 hours; and if it is a 
case of nervous men, without exception, 
even 10 hours, in which case it is per- 
missible that a half, possibly a whole, hour 
of this is transferred to the afternoon. 

As a matter of course, I will advise none 
to sleep longer than he did before the 
treatment unless he was accustomed to 
stay awake over drinking bouts, etc. 
There are three reasons for the liberality 
which I employ in this point. 

First, experience has taught me that 
the treatment has never been hindered 
by patients sleeping 9 and, in exceptional 
cases, even 10 hours. 

Second, that stricter orders meet with 
the most violent resistance or are not fol- 
lowed at all. 

Third, that when they are followed, 
without exception all sorts of complaints 

269 



DIETETIC TREATMENT 

about nervous disturbances are heard, 
about ill-humor, headache, giddiness, 
ravenous hunger, etc., which do not make 
it seem advisable to insist upon the order 
which restricts sleep. This is true very 
particularly of the siesta after dinner, 
which is indispensable to many men. It 
frequently happens that patients regard 
this nap after dinner as the only cause of 
their obesity, and for years, even decades, 
struggle against what they believe to be, 
or what they are told, is an extremely 
dangerous habit. Without success ! They 
always lie down again after dinner even 
with bad twinges of conscience. The 
absence of the *' little quarter of an hour " 
would make them ill-humored the rest of 
the day, and incapable of much activity. 

Now, such men are very happy when I 
do not forbid them this source of comfort. 
On this account they are generally ready 
for other renunciations, and they remain 
valiant and persevering. 

As a matter of course, I make use of 
all means to stop excesses of laziness, 
which are incompatible with the treatment. 
This often succeeds in the case of youth- 
ful individuals, whose personalities are 

270 



OF OBESITY 

still impressionable, and who are under 
supervision and guardianship. The 
inertia of older persons is almost always 
an incurable disease. Improvements occur 
during a short residence at a health resort 
or in an institution. After the return 
almost all who have improved suffer a 
relapse. 



271 



CHAPTER XXV 

At the conclusion of treatment I 
instruct my patients as to their further 
procedure. The success attained must be 
retained permanently. The normal or 
maintenance diet is composed on the basis 
of the experiences of the latter weeks of 
treatment. I endeavor to ascertain 
whether the patient has followed the pre- 
scriptions of the treatment exactly during 
this period, or whether and in what direc- 
tion he has deviated from it. It is not 
difficult to determine the regimen desired 
when attention is given to the decrease in 
weight observed, the average of which is 
computed from the latter weeks of the 
treatment. In this connection the foods 
can either be taken into account accord- 
ing to their oxidative value, or the pro- 
cedure can be empirical. I prefer the 
latter way, since several " unknown 
quantities " must be reckoned with, just as 
in the regimen of the treatment, and a cer- 
tain formula for the normal regimen can- 
not be found by a method of computation. 

272 



DIETETIC TREATMENT OF OBESITY 

Therefore I prescribe a regimen which 
seems to be suitable according to experi- 
ence, and correct it by the result obtained. 
In this connection heed must be given to 
the fact that the transition from the treat- 
ment to the normal regimen is always 
attended by an increase in weight which 
can be observed even in the early days, 
since it depends not upon the addition of 
fat but upon increase in the content of the 
stomach and intestine, and which is not 
to he progressive in case the regimen is 
correctly chosen. 

The increase in the early days of the 
normal regimen seldom amounts to more 
than 1 Kg., generally somewhat less. It 
is the same amount by which the weight 
sinks in the first days of a new treatment 
more quickly than during the further 
course. 

The rations of meat are generally suffi- 
ciently large in the regimen of the treat- 
ment, and their increase is only seldom 
and in a small degree permissible in the 
normal regimen. Hence the other con- 
stituents of the diet should be improved, 
and, what is more, as far as possible 
according to the special wishes of the 

18 273 



DIETETIC TREATMENT 

'patient. The more these are met, the more 
the prospect of his continued obedience. 

But in one point I am accustomed to 
turn deaf ears to such wishes : only in ex- 
ceptional cases is it permitted to eat 
bread with the principal meals, almost 
never for daily consumption. It is espe- 
cially in bread-eating that excesses are the 
rule, and then the further taking on of fat 
is given free rein. Relapses are based 
chiefly upon the abuse of the consumption 
of bread. 

I have already mentioned the fact that 
the rule holds as well for the eating of 
bread as for alcohol: abstinence is easier 
to bring about than moderation. It is 
easier to renounce the first mouthful than 
the second and the following ones. Hence, 
even the first must be forbidden. 

It is difficult for many, year in, year 
out, to pay such heed to quality and 
quantity of the food as the maintenance of 
the permanent, equal weight would de- 
mand. Even in the case of such men per- 
manent successes can be attained, and, 
indeed, in two different ways. Either 
they are allowed to observe the regimen 
of the treatment once a year (three or four 

274 



OF OBESITY 

weeks almost always suffice) until the 
additional growth of the year has been 
removed. It is still better if such a supple- 
mentary treatment is begun as soon as the 
weight has increased two or three kilo- 
grammes. Then only two weeks are 
needed to restore the proper balance. 

The second method to observe is a strict 
treatment regimen on a certain day of 
every week. This makes 52 treatment 
days in the year, hence more than 7 weeks 
of treatment. A man must indeed be a 
bad gourmandizer not to keep his weight 
at the same figure in this way. 

Whoever is satisfied to observe the fast 
day as a " milk day " is allowed to take 
one to two litres of milk as the only nutri- 
ment. Most men find the varied fare 
which my treatment regimen allows even 
for the single day less disagreeable, and 
quickly give up the milk days. 

One thing more! Let every obese per- 
son early procure a reliable scales. The 
weight must always be kept in evidence. 
It must not occur that men put on fat 
because they were uncertain for some time 
as to their weight. 

275 



CHAPTER XXVI 

A RELATION exists between the height 
and the weight of man. A tall man or 
woman will appear normal and well-pro- 
portioned at a certain weight, while a 
small person of the same weight looks 
enormously fat. And vice versa! A small 
woman weighing, for example, 55 Kg. 
will make a good model for a painter or 
sculptor, while a tall woman of the same 
weight would be considered only by very 
modern artists as a model for their crea- 
tions, but by us physicians as the object 
of an energetic fattening treatment. 

There is no doubt, no debate about these 
facts. I even believe that those glorifiers 
of the absence of flesh and fat, if they 
should find these conditions in their own 
wives or daughters, would not refuse their 
consent to a correction which would bring 
about a return to those dimensions which 
the rest of humanity considers normal. 

All agree that a enormously fat person 
should be made slimmer, and a man who 
consists merely of skin and bones should 

276 



DIETETIC TREATMENT OF OBESITY 

be fattened. Only those cases give diffi- 
culty in which opinions as to their sym- 
metry vary or can vary. But even in 
the case of those who are fat or thin be- 
yond doubt, and about w^hose need of cor- 
rection all agree, it is a question of deter- 
mining the weight which is to form the 
final goal of the treatment. 

The questions which we and those seek- 
ing help must answer are, therefore: 

(1) Is this individual before us so 
heavy or light that an obesity or a fatten- 
ing treatment is indicated? 

(2) How many kilogrammes are to be 
removed or added? 

It has already been said that the weight 
of man depends primarily upon his 
stature. This opinion is also found in the 
literature of the subject. But there is also 
a long series of investigations by Que- 
telet ^ which has for its subject the de- 
pendence of weight upon age. Such 
determinations are important for the 
period of growth and development, but 
practically worthless for later life. 

The same author ^ has also undertaken 

* Quetelet, Anthropometric, p. 346, cited according to 
Vierordt's data and tables, 2nd edition. 
^Quetelet, Physique sociale. 
277 



DIETETIC TREATMENT 



statistical inquiries as to the relation of 
height and weight, and thus estab- 
lished the following figures : 



Height in centimetres. 


Weight in kilogramines. 


Men. 


Women. 


140 
150 
160 
170 


34.48 
46.29 
57.15 
63.28 


37.18 
48.00 
56.73 
65.20 



Krause^ computes 2.9 cm. (!) increase 
in height for 1 Kg. increase in weight in 
proportionate bodies. This doubtless 
false assumption is based upon the measur- 
ing and weighing of the corpses of sui- 
cides. The number of observations was 
small and gave rise to the false conclusions. 
A fairly well-known rule, attributed to 
Allaire and Robert, requires that one must 
weigh as many kilogrammes as one ex- 
ceeds 100 cm. in height. Hence: 
50 Kg. for 150 cm. height. 

for 160 cm. height. 

for 170 cm. height., etc. 

has proposed the follow- 



60 Kg. 
70 Kg. 

Bernhardt ^ 



' Krause, Anatomie, 3rd edit., vol. 2, p. 11 and 949 f. 
* Borchardt, Petersburger med. Wochenschr., 1886, 



p. 108. 



278 



OF OBESITY 

ing formula for the determination of the 
correct weight: 

240 

in which P signifies the weight in kilo- 
grammes, H the height in centimetres, and 
C the average chest measurement taken 
over the nipples, in centimetres. 

Frohlich ^ finds fault with this rightly, 
and emphasizes the fact that three quanti- 
ties, length, breadth, and depth, should be 
employed, for weight is a cubical concep- 
tion and therefore to be computed from 
three quantities. 

As we will see, the core of the matter is 
thus reached, and it would have needed 
only one more calculation to solve the 
problem. 

Dr. R. Livi ^ employs a somewhat com- 
plicated reckoning in order to ascertain 
the relation between height and weight. 
He ascertains the " indice ponderal " by 
determining (according to a report in 
Schmidt's Year Books) "the relation of 

'^ Frohlich, Eulenburg's Realencyklopadie, 2nd edit., 
article " Bodyweight," in the Allg. med. Centralzeituntr, 
1894, Nr. 103, and 1895, Nr. 1-3. 

^ R. Livi, L'indice ponderal. Archive ital. de Biologic, 
cited according to Schmidt's Year Book, vol. 2GQ. 
279 



DIETETIC TREATMENT 

the hundred-fold radius of a cyhnder 
(whose height would be equal to the height 
of the individual and whose volume would 
be equal to a volume of water of his 
weight) to his height." 

Livi also objects energetically to all 
attempts to place height and weight in 
direct proportion, because it is false to 
place a cubic mass parallel to a height 
mass. 

E. Schmidt"^ has determined for the 
school children of Freiburg that the weight 
up to the age of 11 is almost in quadratic 
relation to the height, but later increases 
at a comparatively quicker rate. 

As a matter of fact, it is clear to every 
one endowed with a little mathematical 
sense that the weights of bodies which 
must be geometrically similar to one an- 
other cannot be computed according to a 
formula in which only the first power of a 
dimension or, as Bernhardt claims, the 
product of the two linear dimensions are 
contained. 

But, first of all, I would like to express 
my conviction that the statistical method, 

^ E. Schmidt, Korrespondenzenblatt der deutschen 
anthropol. Ges., 3892. 

280 



OF OBESITY 

the determination of the average values 
of different individuals, should not be used 
in order to find the measure with which 
the others are to be measured. There 
may occur so many deviations from the 
norm according to the material which is 
at the disposal of the measurer, which tend 
in the same direction, that entirely false 
results could come to light. 

The " too heavy ones " and the '' too 
light ones " are both abnormal, and it is 
wholly improbable that they are mixed 
in the correct relation so that we would be 
able to construct from their average the 
man of ideal stature. 

This also explains the fact that the 
values determined by various authors 
differ very greatly. 

Only one solution of the problem seems 
to me justified. Artists or other men en- 
dowed with artistic sense would have to 
select from a great number of well- 
formed, unclothed persons the hand- 
somest man and the handsomest woman. 
These two individuals would then be 
measured and weighed, and the values 
found used as the norm and measure. 

According to my recollection, there have 

281 



DIETETIC TREATMENT 

actually been such men's beauty contests 
dealing with the structure of the body. 

We might also declare two creations of 
a great sculptor, man and woman, as the 
normal man and woman, and use them 
for our purposes. 

They would have to be erect, naked 
figures. Good copies of plaster, with no 
hollow space in the centre, would have to 
be prepared, while pedestals, accessories, 
etc., and hair adornments would be re- 
moved. Then the figure would be weighed 
and its volume determined by comparing 
the weight with the specific weight of the 
material. The specific weight of man is 
known. It varies in healthy individuals 
with the normal nutritive condition within 
certain narrow limits. Hence nothing is 
easier than to ascertain how heavy, for 
example, the Apollo of Belvedere would 
be in flesh and blood. 

Nor would it be difficult to determine 
his correct height, although he does not 
assume the attitude of the recruit under 
measurement. A well-proportioned man 
is made to assume the position of Apollo, 
and the vertical distance from top to toe 
is measured. Then he is placed upright, 

282 



OF OBESITY 

and it is ascertained by what per cent, 
his height lias increased. The height of 
the Apollo would have to be corrected in 
the same ratio, in order to learn its 
" measure of ascent." 

It would not be at all necessary to 
select a copy in natural size for this ex- 
periment. Copies on a small scale would 
suffice. We would have only to ascertain 
the formula by which we can convert the 
weight. 

We can arrive at this formula empiri- 
cally or by a simple mathematical calcula- 
tion: empirically, by comparing the 
weights of two copies of the same object 
differing in height. If we take, for ex- 
ample, a statuette 10 cm. in height and 
another one 20 cm. in height, we find the 
latter eight times as heavy as the former. 
Hence the weights are to each other as 
the third powers of the heights. This can 
be developed mathematically as follows: 

If P, P' be the weights, V, V the vol- 
umes of two similiarly built, hence 
geometrically similar, figures with the 
heights h, h' and the greatest breadths, 
measured perpendicular to the line of 
height, h, h\ then we have first — (by s is 



DIETETIC TREATMENT 

understood the average absolute weight 
of every unit of volume) : 

P=Vs, P'=V's 

( \ P ^ Vs _ V 

^^^ P' V's V 

, , h h 

<^) -F = T- 

At the same time, by virtue of the 
geometrical similarity of both individuals, 
the relation of V (the volume) is to % h- 
7t h of a circular cylinder of equal height 
h and diameter b as the relation of V (the 
volume) is to % b'^ n h' of the correspond- 
ing circular cylinder with the height h' 
and diameter V; that is ; 





V: — b'Trh=V': -b'-'-ivh' 
4 4 








Thereupon it follows V : 
h\ hence with reference to i 


(2) 


= b'h 


:b'' 


.^3)... 


V fby h f h 
— V \bO h' \h 


'J h' 






SO that 
finally 

(4)... 


according to (1) 

P ¥ 


we 


have 


also 



Hence the weights are to each other as 
the third powers of the heights. In this 
connection it is a matter of no importance 

284 



OF OBESITY 

according to what units of measure P, P'; 
h^ W have been determined, because these 
units of measure fall out when P is 
divided by P' and h by hf. 

Individuals of the most different heights 
can correspond to the ideal set up by us, 
if the proportions of their bodies are like 
those of the ideal man, if they are geo- 
metrically similar to the latter. 

As already mentioned, we can regard 
the specific weight of healthy, normal men 
as constant. Hence the weights of men 
who are geometrically similar to one an- 
other are proportional to the third power 
of their heights. 

It is very important that the breadth 
and thickness of the body are not con- 
tained in the formula which we use. For 
these dimensions change with the nutritive 
condition (the height does not!). Hence 
if breadth and thickness were present as 
factors, as in the formula of Bernhardt, 
we wbuld learn at most, after measuring 
an obese person, how heavy he is (but the 
scales tell us this more reliably), but not 
how heavy he ought to be, as we wish to 
know. 

The experience which I have had with 

285 



DIETETIC TREATMENT 

2000 men coincides perfectly with the rule. 
If we consider a man symmetrical, who is 
170 cm. tall and who weights 70 Kg., this 
is also the case with a man 160 cm. tall, 
weighing 58.4 Kg., while a man 190 cm. 
tall must weigh 97.70 Kg. 

Now, we must still agree as to the 
masculine and feminine ideal which is to 
form the basis of our computation. 

Since we do not exactly wish to make 
our patients models for Greek gods, we 
need not be too severe. The norm of 
weight is not a definite figure in every 
case; it lies within two bounding values 
which differ by some kilogrammes. 

Aside from the height of the body, there 
still remain different factors which in- 
fluence the weight and which must be 
taken into consideration in estimating 
deviations from the norm. 

The age is such a factor; Quetelet 
found, as already mentioned, by a statisti- 
cal method, that men become lighter with 
increasing age. The observation of the 
members of a large class who do not live 
in poverty (so far as I can judge, of 
all nations) teaches the contrary. It is 
seen that the majority of individuals be- 

286 



OF OBESITY 

ginning with the 25th year put on fat, 
and there is no doubt that the average 
weight of men who are regarded as nor- 
mal (hence, after separation of the in- 
valids and obese) rises with increasing 
age (from the 20th to the 60th year of 
life). 

The fifties of the woman, the time of the 
climacteric, would in that connection 
correspond to an upward break in the 
weight curve. As already mentioned, this 
time is also critical for the shape of the 
body. The powerful influence of the 
generative glands upon tissue-change is 
thus expressed. 

Hence we will estimate the " permissi- 
ble " weight higher for an obese elderly 
man than in the case of a young one of 
the same height. I consider a " quinquen- 
nial addition " of 1 Kg., reckoned from the 
25th year, to be correct. 

The circumstances are different in the 
case of candidates for fattening treat- 
ments. We are seldom confronted by the 
necessity of attempting such treatments 
in the case of old people, still less of carry- 
ing them out successfully. 

Hence it is of no urgent practical inter- 

287 



DIETETIC TREATMENT 

est to know whether the weight of an old 
person has gone below the permitted mini- 
mum. At any rate, it can be considered 
well established that a somewhat too low 
weight is no indication for a fattening 
treatment after the age of 50. 

A second factor which deserves atten- 
tion and consideration is the oft-present 
disproportion between limbs and body. 
There are obese people (not seldom 
among women) whose " ballast " weight 
has been added exclusively to the body, 
while arms and legs are slender and well 
formed. The weight of such people is 
easily overestimated, if they are not seen 
undressed. Since with them the fat is con- 
centrated in single places, the cosmetic 
effect of an obesity treatment will only 
be fully recognized when the weight has 
been reduced to a value very close to the 
norm. In the case of the symmetrical dis- 
tribution of fat on body and limbs, or in 
the case of excessive participation of the 
latter in obesity, and especially in the case 
of powerful development of the bony sys- 
tem — large hands and feet — the permissi- 
ble weight is to be estimated higher than 
in the case of men with delicate limbs. 

288 



OF OBESITY 

Above all, attention must be given to 
the development of the muscular system. 

According to Vierordt {loc, cit.), the 
muscular system of an adult male amounts 
to no less than 43.40 per cent, of his total 
weight. 

Krause {loc. cit.) found in the case of a 
suicide weighing 69.7 Kg. that the muscles 
weighed 29.1 Kg. = 41.8 per cent., in the 
case of a woman weighing 55.4 Kg. that 
the muscles weighed 19.8 Kg. = 35.8 per 
cent. 

The lowest figure ascertained in the 
case of an adult female (by Dursy) 
amounted to 14.7 Kg., the highest (by 
Bischoif ) in the case of a man 30.6 Kg. 
But these figures certainly do not repre- 
sent the extreme values. They teach us 
that we have to take into account as 
muscles several kilogrammes of the excess 
weight found (more exact directions are 
not necessary) when the muscular system 
is unusually developed. 

The more powerful development of the 
muscular system of man is also the most 
important cause for the greater weight of 
man as compared with that of woman of 
the same stature. The more powerful 

19 289 



DIETETIC TREATMENT 

bony system is the second factor. The 
weight of the skeleton amounts to 17.5 
per cent. (Vierordt), hence only two- 
fifths of the muscle weight, and the differ- 
ences of the weight of the skeleton in 
different individuals are much less than 
those of the weight of the muscles. 

The following tables are constructed on 
the supposition that a well-proportioned 
man, 25 years old, with a well-developed 
muscular system and 170 cm. in height, 
ought not to weigh more than 70 Kg., and 
that a well-proportioned woman, 25 years 
old and 165 cm. in height, not more than 
60 Kg. 

I hope that this assumption, which is 
arbitrary, but is advanced on the basis of 
numerous observations, will be accepted. 
Then the table would give immediate in- 
formation as to how heavy men and women 
of varying stature ought to be, may be. 

But if anyone should wish to take other 
normal values for the man 170 cm. tall and 
for the woman 165 cm. tall as a starting 
point, he will not find difficulty in com- 
puting himself, with the aid of the formula 
developed above, the appropriate figures 
for the other height values. 

290 



OF OBESITY 

The figures refer to undressed indi- 
viduals. The clothing of men (without 
outside wraps) generally weighs in sum- 
mer between 3 and 4 Kg., in winter 4 to 
5 Kg.; that of women, 2 to 3 and 3 to 4 
Kg., respectively. 





Weight, Kg. 




Weight, Kg. 


Height, 






Height, 






cm. 






cm. 








Men. 


Women. 




Men. 


Women. 


145 




40.7 


173 


73.8 


69.2 


146 





41.5 


174 


75.1 


70.4 


147 





42.4 


175 


76.4 


71.6 


148 


.... 


43.3 


176 


77.7 


72.8 


149 




44.2 


177 


70.0 


74.0 


150 


48 .'i 


45.1 


178 


80.3 


75.3 


151 


49.0 


46.0 


179 


81.7 


76.6 


152 


50.0 


46.9 


180 


83.1 


77.9 


153 


51.0 


47.8 


181 


85.5 


79.2 


154 


52.0 


48.8 


182 


85.9 


80.5 


155 


53.0 


49.8 


183 


87.3 


81.8 


156 


54.0 


50.8 


184 


88.7 


83.2 


157 


55.1 


51.8 


185 


90.1 


84.6 


158 


56.2 


52.8 


186 


91.6 


86.0 


159 


57.3 


53.8 


187 


93.1 


87.4 


160 


58.4 


54.8 


188 


94.6 


88.8 


161 


59.5 


55.8 


189 


96.1 


90.2 


162 


60.6 


56.8 


190 


97.7 


91.6 


163 


61.7 


57.8 


191 


99.3 


93.1 


164 


62.8 


58.9 


192 


100.9 


94.6 


165 


64.0 


60.0 


193 


102.5 


96.1 


166 


65.2 


61.1 


194 


104.1 


97.6 


167 


66.4 


62.2 


195 


105.7 


99.1 


168 


67.6 


63.3 


196 


107.3 




169 


68.8 


64.4 


197 


108.9 




170 


70.0 


65.6 


198 


110.5 




171 


71.2 


66.8 


199 


112.2 




172 


72.5 


68.0 


200 


113.9 





291 



APPENDIX 

FATTENING TREATMENT 

The treatment of abnormal leanness 
(fattening treatment) is the opposite of 
the treatment of obesity, its purpose being 
to remove a defect in the fatty content, 
and, as a rule, in the muscular content of 
the organism. 

We must understand in the beginning 
that, in general, it is more difficult to suc- 
ceed in the fattening treatment than in 
the treatment of obesity. In the latter 
condition treatment is successful always 
and without exception, unless obstinacy 
or deficient strength of character in the 
patient brings our endeavors to naught. 
Fattening treatments, on the contrary, 
can be wrecked on various cliffs. Their 
success presupposes a certain degree of 
functional soundness on the part of all 
organs that serve in the assimilation of 
nutriment. A man who suffers from 
cancer of the stomach, or from some other 
severe gastric or intestinal affection, can- 
not usually be fattened. And there are 

292 



DIETETIC TREATMENT OF OBESITY 

other affections, especially those accom- 
panied by fever, and, above all, tubercu- 
losis, as well as many abnormalities in 
tissue-change, which oppose great and 
sometimes insuperable obstacles in the 
way of attempts to increase weight. 

Hence, it is plain that the prospect of 
success in any fattening treatment will 
vary according to the cause of the under- 
nourishment. A good prognosis can be 
made in those cases in which there is no 
doubt that the cause is to be found in in- 
sufficient or irrational feeding; and this, 
whether the patients have restricted the 
amount of their food from a morbid fear 
of obesity, or whether their loss of appe- 
tite is a result of sorrows or cares. 
(" Love-sorrow " is a frequent source of 
morbid leanness.) In these cases the 
patient takes but small quantities of food, 
and these with reluctance, the entire 
amount being insufficient to maintain his 
nutritional equilibrium. 

These latter forms of undernourishment 
undergo spontaneous cure as soon as the 
cause is removed. It is universally known 
that a change of residence or of surround- 
ings, or a pleasure-trip has a favorable 

293 



DIETETIC TREATMENT 

effect upon the mental condition of the 
patient and indirectly upon his nutrition. 
But even in these cases definitely formu- 
lated directions as to the kind and quantity 
of the food to be taken are of value. 

Then, too, there are cases of morbid 
leanness (to which reference has been 
made in another connection) which seem 
paradoxical. The patients, usually girls 
or young women, are not seriously sick — 
at least, so far as this can be determined 
during life by present-day methods. They 
have no great sorrow or care, except that 
they wish to put on flesh. Acting of their 
own accord or upon the advice of physi- 
cians or friends, they have tried, often for 
years, the means available to them for the 
removal of their burden. They eat as 
much as they can hold, and usually more 
than their healthy and normal looking 
brothers, sisters, and friends of the same 
age. They are large consumers of the 
various concentrated or predigested forms 
of nutriment. Close observation shows 
that at times digestive abnormalities, 
usually trifling, are present. The appe- 
tite leaves much to be desired. Eructa- 
tions, heart-burn, and a feeling of disten- 

294 



OF OBESITY 

tion are present after meals, and the 
bowels are usually irregular. A " sensi- 
tive stomach " is found with especial fre- 
quency. Lauder Brunton compares the 
stomach of a certain fortunate class of 
men to a Wedgewood mortar, which can 
be hurled violently to the ground or be- 
labored with a hammer and yet remain 
whole and uninjured. On the other hand, 
there are men whose stomachs resemble a 
vessel of thinnest porcelain. Gently 
handled, it remains sound and uninjured 
up to a great age. But every inconsider- 
ate or slight blow may shatter it in pieces. 
Such fragile stomachs are not infrequently 
found in the case of those with whom we 
are now concerned. A somewhat too rich 
or too abundant meal, the use of certain 
kinds of food, even in the smallest 
quantity, causes vomiting or, at least, loss 
of appetite for days, or some other dis- 
turbance, and considerably reduces the 
body weight, which by laborious effort had 
been increased a little. 

That an increased diet leads to the addi- 
tion of fat is known to every child. When 
a man is too lean and feels that his condi- 
tion is unpleasant, ugly, or dangerous to 

295 



DIETETIC TREATMENT 

health, he will try to eat more than has 
been his custom. And if lie does not do 
this of his own accord, he will be urged to 
do it by those about him. 

It is also true that among educated 
people correct conceptions as to the value 
of different foods as fat-builders are the 
rule. It is generally known that fats and 
carbohydrates occupy the first place ; that 
butter, cream, and farinaceous foods are 
very useful in causing an increase of fat, 
and that, on the contrary, other foods and 
food constituents exhibit little nutritive 
value and should not be allowed to usurp 
the limited space in the stomach, needed 
for more nutritious articles of diet. 

All this is well known and heeded, 
whether medical advice is sought or not, 
and yet there are countless failures. The 
poor victims go to no end of trouble and 
yet remain thin and lean. 

I have given advice to quite a number 
of cases (about 100) belonging in this 
category, and in about 75 per cent, of 
them have secured marked and lasting 
success. 

The history of the cases with favorable 
outcome showed without exception that 

296 



OF OBESITY 

the patients had (before coming to me) 
eaten enough food. If this food had been 
really digested and assimilated, a rapid 
accumulation of fat would inevitably have 
followed. It did not appear, however. 
Hence it seems clear that the food was not, 
or not entirely, assimilated. Closer in- 
vestigation never failed to show that the 
digestive disturbances mentioned above 
were present. Absent or insufficient appe- 
tite was almost always noted. With these 
patients eating is usually accompanied by 
a feeling of disgust rather than pleasure. 
And this the more if they are required to 
consume nourishing but disagreeable 
foods. 

With reference to Pawlow's investiga- 
tions regarding the influence of the sense 
impressions (smell, appearance of the 
food, and its palatability or non-palata- 
bility) upon the secretion of the digestive 
juices, the disregard of the wishes and 
tastes of the individual patient must be 
regarded as a gross error. I have sought 
to avoid this by never forcing my patients 
to take food or drink which was repug- 
nant to them. It IS necessary to find 
dishes or methods of preparation that are 

297 



DIETETIC TREATMENT 

agreeable or, at least, not repugnant to 
the patient. 

In this connection the inclination of 
many patients to eat bread, possibly even 
to eat certain kinds of bread, often stood 
me in good stead. They are generally very 
glad to eat bread and butter. 

If beef is refused, then ham, poultry, 
fish, possibly even eggs or cheese, and 
potcheese should be tried as a substitute. 
An expedient can always be found if one 
takes the trouble to seek it. 

Tasteful preparation (best butter as 
cooking fat) is very essential. Then, too, 
one should not forget that, given the same 
constituents, a much more palatable dish 
can be prepared by a good cook than by 
one less gifted. 

But the most important thing is not to 
give more nutriment than the organism 
of the patient can easily digest and assimi- 
late. More than this does no good, but, on 
the contrary, does harm: on the one hand, 
because it overburdens the digestive organs 
and causes decomposition processes, which 
can lead to toxaemias and occasional diges- 
tive disturbances ; and, on the other hand, 
because so much chemical energy is re- 

298 



OF OBESITY 

quired for disposing of this excess that no 
real additions of material can follow. Both 
circumstances combine to hinder the gain 
in weight. 

In the case of men who were large eaters 
and yet remained pathologically lean I 
succeeded by limiting the nutriment. 

As in the case of the reduction treat- 
ment, the fact that I was not obliged to 
complete the cure in an allotted time, but 
could take as much time as I chose, was 
of great advantage. The patients, for the 
most part, remained in their accustomed 
environment. Only when the disturbing 
psychical influences mentioned above 
could be demonstrated was institutional 
treatment, or at least a change of environ- 
ment, undertaken. 

The treatment is begun by placing the 
patient upon a diet containing approxi- 
mately sufficient nourishment to maintain 
his present status. 

In the choice of foods we are guided, 
on the one hand, by the tastes of the 
patient (when these are not entirely un- 
reasonable), and, on the other hand, by 
the condition of the digestive organs. In 
some cases coarse food is prescribed, in 

299 



DIETETIC TREATMENT 

others food that is more delicate and more 
easily digested. All dishes are weighed. 

The methods (cited in Chapter XII) 
which serve to increase pleasurable sensa- 
tions in eating are employed. The inser- 
tion of a mouthful of bread between 
several mouthfuls of meat, and of a drink 
of water or milk between the single 
courses, but especially the alternation in 
the fare, contribute to free the treatment 
from everything which is felt as disagree- 
able compulsion. 

When familiarity with the nutritive re- 
quirements of the patient has been gained 
by several days of normal diet, the food is 
slowly and cautiously increased and the 
body weight is recorded. The latter, for 
reasons already stated, has decreased 
somewhat in the first few days. The 
stomach and intestinal contents have be- 
come lighter as a result of the restriction 
in diet, and there has been a correspond- 
ing reduction of the total weight. 

But now the latter begins to mount. 
The rate of increase is of very little mo- 
ment in these cases. The steadiness of 
the increase and, above all, the health of 

300 



OF OBESITY 

the patient are the important considera- 
tions. I am well satisfied with weekly 
increases of 0.50 Kg. or even 0.25 Kg. 
I consider it advisable to exceed 1 Kg. a 
week only when the patient desires more 
abundant fare, as occasionally happens in 
the course of the treatment. 

Even in the days of normal diet, the 
little troubles about which the patient at 
first complained — flatulence, feeling of 
tension in the stomach, heart-burn, 
and inclination to diarrhoea — disappear. 
These disturbances should not appear 
again during the treatment. If they do, 
it is evidence that a reduction in quantity 
or a change in quality of the diet is 
indicated. 

For the delicate balancing of the nutri- 
tive value of the entire diet, nothing is 
better than milk, in combination with tea, 
cocoa, coffee, oatmeal, or even the 
" puffed " foods which serve as infant 
foods, e.g., Kufeke's Infant Food. 

There are men with whom ordinary 
milk does not agree, but who can easily 
digest the '' FettmilcW which I dis- 
covered, a milk poor in casein, but rich 
in fat, more like mother's milk in com- 

301 



DIETETIC TREATMENT 

position, and forming soft curds in the 
stomach. 

I prefer to have sweet milk or '' Fett- 
milch'' cold or warm, taken at the princi- 
pal meals instead of other liquid. As is 
well known, it is best borne when taken in 
this way. I also often use the Bulgarian 
sour milk (Yogurth). 

I do not think it advisable to give milk 
except with meals. This would really be 
to increase the number of meals and 
thereby to deprive the stomach of its 
needed intervals of rest. JMilk in itself 
constitutes a meal and imposes upon the 
digestive organs demands which should 
not be underestimated. We know that 
nursing infants usually thrive better if 
the number of their meals is restricted. 
The same rule serves for those adults 
whose stomachs will not bear comparison 
with a Wedge wood mortar. 

Patients who have submitted to an en- 
forced fattening cure in institutions re- 
lapse easily into their former mode of life 
when they return home. To continue to 
nourish them as during the period of treat- 
ment seems hardly possible. Those 
patients, on the contrary, who were over- 

302 



OF OBESITY 

nourished under my direction without be- 
ing forced to take certain dishes or great 
quantities of food are able, if necessary, 
to continue the new diet for an unhmited 
time. 

Adults who refuse milk and have an 
urgent desire for a glass of beer may be 
allowed a small quantity of a liquid ex- 
tract of malt. Otherwise I prefer to get 
along without alcohol in the fattening 
treatment. To give alcohol regularly, 
even in the smallest quantity, to children 
and young people is, in my opinion, 
criminal. 

The few examples that follow will serve 
to illustrate my method of procedure. 

No. XIV, M, the S6-year-old wife of an at- 
torney (who was at the same time taking an 
obesity treatment), married for 7 years, 
mother of two children, aged 6 and 4 jears. 
The patient is 170 cm. tall. When she was mar- 
ried she weighed 64.5 Kg., and wishes most 
anxiously to attain this weight again. Looks 
pale, has no appetite. Menses accompanied by 
great loss of blood. Poor sleep. Otherwise no 
complaints. In the endeavor to put on fat she 
has observed the following rich diet: 

Morning: Cocoa, two rolls, butter. 
303 



DIETETIC TREATMENT 

Ten o'clock: One-quarter of a litre of milk, 
bread and butter, fruit. 

Noon : Soup, roast, vegetables, potatoes with 
sauce, farinaceous food, three-tenths litre milk, 
bread. 

Four o'clock: Coffee, one buttered roll. 

Evening: Meat, vegetables, preserves, fruit, 
three-tenths litre milk, bread. 

Ten P.M. : Three-tenths litre milk. 

The patient is a total abstainer. 

Diet of treatment: 

Morning: 200 Gm. of coffee or cocoa with 
cream, 80 Gm. of rolls with butter. Later, also 
one egg, at the request of the patient. 

Noon: 150 Gm. of beef soup with solid con- 
stitutents, 100 Gm. of beef or roast, 100 Gm. 
of green vegetables or potatoes and sauce, 120 
Gm. (increased to 160 Gm.) of farinaceous 
food and bread (taken together), 20 Gm. of 
cheese, 150 Gm. of fruit, one cup of Mocha, 
water as a drink. 

Five o'clock: 150 Gm. of coffee with cream, 
40 Gm. of buttered rolls. 

Evening: 100 Gm. (later 110 Gm.) of any 
roast or fish or cold meat, 120 Gm. (increased 
to 180 Gm.) of potatoes or noodles, macaroni, 
etc., as a side dish ; also lettuce or preserves as 
desired, one buttered roll, water as a drink. 

Hence two meals or milk were omitted. The 
amount of food allowed was, however, otherwise 
304 



OF OBESITY 

decidedly smaller than that before the begin- 
nincr of the treatment. 

The following table gives information con- 
cerning the progress of the treatment: 



Date. 


Weight 

with 
clothes. 


Remarks. 


September 18, 1905 

September 25 


60.30 
59.70 
60.00 

60.95 

61.10 
62.50 
62.80 
63.30 
63.55 


Beginning of treatment. 
Initial fall in weight. 


October 2 


Mental excitement. Death 


October 9 


in family. 

Appearance better. Ap- 
petite good. 

Menses. 


October 16 


October 23 ... 


Perfect health. 


October 30 . ... 




November 6 




November 20 


Menses passed. Perfect 
health. Good appear- 
ance. 





According to reports of the husband, 
the weight rose still higher. The patient 
bore a third child, which she nursed her- 
self. During this time her weight in- 
creased still more. The lady adheres 
firmly to the principle of the diet which 
I prescribed, and enjoys a normal nutri- 
tive condition and perfect health. 

No. VI, 15, the 23-year-old vocal student, 
now an opera singer, is 167.5 cm. In height, and 
on the day when she began the treatment, Feb- 
ruary 9, 1905, weighed 57.10 kilos, (with cloth- 
ing) . She has endeavored for a long time to im- 
20 305 



DIETETIC TREATMENT 

prove her nutritive condition by heavy eating. 
Without success ! Appetite varying. Bowels 
regular. Formerly constipated. Menses very 
irregular, the last time five months ago. The 
following treatment regimen represents a re- 
striction in diet compared to her previous diet: 

Morning: 200 Gm. of coffee with cream, one 
buttered roll, SO Gm. of ham, or one egg. 

Noon: 200 Gm. beef soup with solid con- 
stituents, 100 Gm. of beef or roast, 150 Gm. 
vegetables, also sauce and potatoes ; 150 Gm. 
of salted or 80 Gm. of sweet farinaceous food. 

Added later, a half litre of milk with meals. 

Five o'clock : 200 Gm. of coffee or cocoa, one 
buttered roll. 

Evening: 130 Gm. of roast or 100 Gm. of 
cold meat, or three eggs; 150 Gm. of potatoes 
or 120 Gm. cf noodles, macaroni, etc. ; 40 Gm. 
of black bread, 100 Gm. of fruit. 



Progress of 


Treatment (In Abstract). 


Date. 


Weight 

with 
clothes. 


Remarks. 


January 26, 1905 

February 8 

March 18 


57.10 
55.80 

57.60 
58.75 
60.55 
61.00 


Beginning of treatment. 
Initial fall in weight. Eu- 
phoria. 
Good appetite. Euphoria. 
Good appetite. Euphoria. 


April 10 


May 13 


Good appetite. Euphoria. 


June 30 


Good appetite. Euphoria. 





306 



OF OBESITY 

With that the treatment is ended. The 
patient, however, follows the direction 
given in substance even longer. Her 
weight rises still more. On September 25, 
1907, it amounts to 64.70 kilos.; on Feb- 
ruary 15, 1908, to 64.90 kilos.; on Ainil 
24, 1908, to 65.70 kilos., and on September 
28, 1912, to 70.80 kilos. Menses in fairly 
good shape for years. 

No. XXXI, 7, the SS-year-old single lady, was 
never seriously sick. On February 3, 1908, she 
weighed 51.80 kilos, in her clothes, height 171 
cm. As long as she can remember she has al- 
ways been too thin. Small bones, weak 
muscles. Pale appearance. Organs without 
pathological findings. Appetite leaves much to 
be desired. Pressure in the region of the 
stomach after abundant meals. Tendency to 
diarrhoea. Looseness always appears after ex- 
citement of any kind. Menses regular since 
13th year. Different attempts to increase her 
weight fail. Sleep 11 hours. Little exercise. 

Regimen of treatment. 

Morning : 250 Gm. of cocoa with cream con- 
taining 6 per cent, fat, 50 Gm. of buttered 
rolls. 

Noon: 150 Gm. of any soup, 90 Gm. of roast 
or beef, 100 Gm. of vegetables, also potatoes 
or leguminous vegetables in puree form; 140 
807 



DIETETIC TREATMENT 

Gm. of farinaceous food, especially salted (in 
exceptional cases also sweet), (of these only 
100 Gm) ; 20 Gm. of bread, three-tenths of a 
litre (later one-half litre) of boiled cold milk. 

Five o'clock: One-quarter of a litre of yog- 
hurt (later 200 Gm. of coffee with cream) and 
50 Gm. of buttered rolls. 

Evening: 70 Gm. of ham or other cold meat 
and 50 Gm. of buttered rolls, or 100 Gm. of 
warm roast and 150 Gm. of potatoes or 100 
Gm. of rice or noodles, etc., daily, at the urgent 
wish of the patient, one-half litre of pasteurized 
Spatenbrau beer. Patient is convinced that she 
ate more before than durinor- the treatment. 

o 

Progress op the Treatment. 



Date. 



February 3, 1908 
February 11 ... . 

February 18 ... . 

February 25 ... . 

March 3 

March 10 

March 17 

March 24 

March 31 



clothes. 


51.80 


53.00 


54.60 


55.30 


55.40 


56.55 


56.65 


56.85 


57.00 



Remarks. 



Beginning of treatment. 

Menses on February 10th. 
Normal movements of 
bowels since beginning 
treatment. 

Bowels normal. Diarrhoea 
only once after dietetic 
error. 

Euphoria. Better appear- 
ance. Bowels normal. 

Euphoria. 

Menses on March 9th. 

Euphoria. 



Euphoria. 
Euphoria , 

somewhat 

ing. 



Weighed in 
lighter cloth- 



308 



OF OBESITY 

Patient appears to be in blooming 
health. Consumes her meals with good 
appetite, and no longer feels pressure in 
the stomach. Bowels normal for many 
weeks. 

The mode of nutrition is retained in 
substance. On August 27 I saw the 
patient again for the last time. Her 
weight amounted to 57 Kg. 

No. 1, 26, the 30-jear-old childless wife, is 
168 cm. tall and weighed at the beginning of 
the treatment on February 15, 1904, 55.30 Kg. 
in her clothes. Too lean since childhood. Eats 
as much as possible. No appetite. Bowels and 
menses regular. Regimen of treatment : 

Morning: 250 Gm. of malt cocoa, 60 Gm. 
of buttered rolls, two yolks of eggs. 

Noon : 100 Gm. of concentrated beef soup, 100 
Gm. of roast, 100 Gm. of potato puree or 
spinach or boiled lettuce, 150 Gm. of " salted " 
farinaceous foods, 80 Gm. of preserves, one 
glass of water. 

Five o'clock: 200 Gm. of weak coffee with 
milk, and one buttered roll. 

Evening: 100 Gm. of cold meat and one 
buttered roll, one glass of wine, and one glass 
of water. 



DIETETIC TREATMENT 

Progress of Treatment (in Abstract). 





Weight 




Date. 


with 
clothes. 


Remarks. 


February 15, 1904 


55.30 


Beginuing of treatment. 


March 1 


56 00 


Euphoria. Appetite excel- 
lent. 






April 25 


57 60 


Euphoria. Appetite excel- 
lent. 






December 7 


60.00 


Euphoria. Appetite excel- 
lent. End of treatment. 


February 22, 1905 


02.20 


Patient always eats accord- 
ing to the scales. Feels 
perfectly well and looks 
blooming. 


April 1,1912 


63.00 


After eight years patient 
presents herself again. 
The success of the treat- 
ment, as can be seen, is 
permanent. 



No. XXIII, 28, the 24-year-old opera singer, 
was never seriously sick. A month ago influ- 
enza, with slight fever of short duration. 
First menses at the age of 13, then menopause, 
lasting a year, caused by chlorosis ; since then 
menses again regular. Violent migraine once 
or twice a month " from the stomach." No ap- 
petite. Many dishes, for example sausage, do 
not agree with her. Bowels constipated. Lit- 
tle exercise. 

Has always been too lean since childhood. 
Attempts to put on fat and flesh by large eat- 
ing and frequent meals without success. 
310 



OF OBESITY 

Weight in clothes on June 22, 1906, 51.60 
Kg., with a height of 166 cm'. I prescribed the 
following diet, which represents a restriction 
compared with the one accustomed : 

Morning: 200 Gm. of coffee with cream., one 
buttered roll. 

Noon: 150 Gm. of soup with solid constitu- 
ents, 110 Gm. of roast, 150 Gm. of vegetables, 
120 Gm. of farinaceous food, 25 Gm. of bread, 
200 Gm. of fresh fruit or preserves, one-half 
litre of milk. 

Five o'clock: 200 Gm. of coffee with cream, 
one buttered roll. 

Evening: 120 Gm. of roast, 150 Gm. of 
potatoes, rice, macaroni, etc., 20 Gm. of bread; 
also lettuce and cucumbers as preferred, one- 
half litre of milk. 

Three months later, on September 19th, 
the weight was 59.30 Kg., hence 7.70 
Kg, higher than at the beginning of the 
treatment. Migraine extremely seldom. 
Appetite excellent. Bowels in order. The 
success remained permanent. 

No. XXVI, 15, the 18-year-old clerk, sur- 
vived a catarrh of the apex pulmonis. At that 
time had a fever for four weeks. Now neither 
coughing nor other symptoms exist. Menses 
regular since the age of 16. Patient complains 
311 



DIETETIC TREATMENT 

of lack of appetite, is a light eater. Digestion 
in order. Every day she takes a walk of an 
hour. Sleeps 11 hours. Has always been too 
lean. 

The former diet consisted of five meals. Ap- 
parently no change has been made in the diet, 
except that the patient's food is regulated by 
the scales. The weight rises from 49.30 Kg., 
on the day when the treatment was begun, grad- 
ually to 55.65 Kg. in the course of four months, 
and it remains permanently at the latter figure. 
At the same time the patient feels very well and 
eats her meals with a good appetite. 



S12 



CONCLUSION 

I TAKE the position of those who assume 
that very many consume more nourish- 
ment than they should. Many of these 
go unpunished. 

According to individual disposition, 
overeating leads in some cases to obesity, 
in others to digestive disturbances. Pyro- 
sis and vomiting are frequent results of 
immoderate eating. Pyrosis is also an 
accompaniment of obesity. Overeating 
often causes (by producing obesity) an 
increase of the blood-pressure. 

Weighing the food facilitates its divi- 
sion according to the particular end in 
view (reduction, fattening, or normal 
diet ) . It aids in the conduct of all rational 
dietetic treatment. 

The incidental uniformity of diet is 
often beneficial to sufferers from migraine, 
reducing the frequency and severity of 
the attacks. 



313